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Whenever you can, count.

—attributed to Francis Galton, 1924

CAPTAIN JAMES COOK: A POPULAR HERO

James Cook in many accounts gets credit for the conquest of scurvy, because, in stark contrast to Anson, he circumnavigated the globe without sustaining a single death from the disease.¹ Although Cook deserves credit for preserving the health of his men and improving the lives of British sailors, he set back efforts to prevent scurvy.²

Cook was born in 1728 to a farming family in Yorkshire, England. He felt the pull of the sea and apprenticed as a merchant seaman at the age of seventeen.³ After rising through the ranks of the merchant marine, he joined the Royal Navy in 1755. He taught himself land surveying and astronomy and mapped the mouth of the Saint Lawrence River and the coast of Newfoundland. More than twenty years of experience as a ship’s officer, expertise in navigation, and a desire to “go farther than any man has been before me” made him an excellent choice to lead a voyage of discovery.

On his first voyage around the world, Cook set out on August 25, 1768, from Plymouth on a refitted coal transport vessel renamed the Endeavour, carrying both sailors and scientists. The Admiralty and the Royal Society jointly sponsored the voyage, one of the first purely scientific naval expeditions in history.

Cook first sailed to Tahiti, where, because of cloud cover, he was unsuccessful in timing the transit of Venus across the sun (from which the distance of the earth from the sun could be calculated). He then turned south to search for the “Great Southern Continent,” believed to exist to balance the land masses in the northern hemisphere. Pundits theorized that without a counterbalancing southern continent, the earth would wobble uncontrollably.

The Endeavour carried provisions for eighteen months at sea, including several putative antiscorbutics: malt (germinated and dried barley), sauerkraut, carrots, marmalade, mustard, saloup (a drink prepared from tree bark), portable soup, and Lind’s rob of lemon and orange. Of these, only the sauerkraut had any value in preventing scurvy.

Of greater importance, the ship could land and reprovision frequently, as it was a time of relative peace. Cook paid attention to the health of his men and was assiduous in obtaining fresh fruits and greens whenever possible. The sailors were initially resistant to these unaccustomed foods until the officers made a show of eating them with gusto, and the sailors eventually came around. As a result, scurvy was never a major problem. After a voyage of two years, nine months, and seventeen days, Cook landed in England on June 12, 1771. Not one of his sailors had died of scurvy.

On his second voyage, Cook again set out to find the Southern Continent, this time with two ships, the Resolution, commanded by Cook, and the Adventure, captained by Tobias Furneaux. The ships departed Plymouth on July 13, 1772, and arrived at the Cape of Good Hope on October 30 with the crews in good health. They departed the cape on November 22, heading south and becoming the first European ships to cross the Antarctic Circle. Signs of scurvy appeared and were effectively treated, probably with sauerkraut. Once again, Lind’s rob was tried and proved ineffective.

After 117 days at sea, the Resolution landed at New Zealand but had become separated from the Adventure in a dense fog. They rendezvoused on April 7 at Ships Cove. Like several prior expeditions, they inadvertently performed an experiment. The crew of the Adventure was suffering from scurvy, having not paid the same attention to diet as Cook’s ship. The men of the Adventure rapidly recovered after eating fresh greens harvested in Ships Cove.

They repeated the experiment when the ships sailed from New Zealand to Tahiti. Three men on Cook’s ship developed signs of scurvy and recovered with treatment. In contrast, thirty of Furneaux’s men were ill with scurvy on arrival at Tahiti. Apparently, Furneaux was unable to learn from experience and provide fresh vegetables and fruits to his men.

The Adventure returned to England while Cook continued searching for the Southern Continent. He explored enough of the Southern Ocean to disprove its existence. Cook continued to land and reprovision with fresh greens and fruits whenever possible. He also served spruce tea to the crew at several stops. As a result, scurvy never was a serious problem on board the Resolution.

Cook landed in England on July 30, 1775. He received an award from the Royal Society for his observations concerning scurvy, and he wrote that malt wort (an infusion of malt prepared in boiling water, a byproduct of brewing beer) was “without doubt one of the best antiscorbutic sea medicines yet found out.”⁴ He did qualify his endorsement by saying that although malt wort would prevent scurvy, “I am not altogether of the opinion that it will cure it in an advanced state at sea.” It is, in fact, worthless in treating scurvy. Cook may have been currying favor with the Admiralty, which favored malt wort, in part because it was much cheaper than lemon juice.

Cook undertook a third voyage in 1776 to search for the Northwest Passage and was killed by indigenous Hawaiians on February 14, 1779. His crew returned to England on October 4, 1780, without discovering the Northwest Passage. The men had all remained in good health, there having been no signs of scurvy.

Cook proved that sailors could undertake long ocean voyages, even in inhospitable climates, without incurring the ravages of scurvy. However, he gleaned only minimal specific information about the disease. His shotgun approach to prevention and treatment—most importantly, frequently landing and restocking with fresh fruits and vegetables—although effective, gave no information about individual measures. He did try Lind’s rob, and its failure was interpreted as a failure of citrus fruits in general. By the time of his death in 1779, Cook had achieved great credibility with the Admiralty, and his opinions influenced policy for more than a decade.

GILBERT BLANE: AN UNSUNG HERO

Although Captain Cook became famous, Gilbert Blane (also spelled Blayne) deserves most of the credit for conquering scurvy in the British Navy.⁵ In the process, he founded the science of epidemiology.

Blane was born in 1749 to a prosperous merchant family in the southwest of Scotland. He went to the University of Edinburgh at age fourteen to study for the clergy, but switched to medicine, spending ten years at the university. He was elected president of the Students’ Medical Society and garnered the good opinion of the faculty, both in the Faculty of Arts and the Medical School.

Armed with letters of recommendation from prominent Edinburgh scholars, he went to London and opened a medical practice.He had a cold manner, later earning the nickname “Chilblaine.” According to one description, “[he exhibited] a certain sanctified, devout, death-like expression of the countenance.” Nevertheless, introduced into London society by a prominent physician, William Hunter, he established a successful medical practice.

One of his prominent patients was Sir George Rodney, admiral of the West Indian fleet, which had been racked with scurvy in previous action. In 1779, Rodney persuaded Blane to abandon his thriving practice and sail to the West Indies as his personal physician. Blane left no record of what led him to give up a comfortable life in London to go off to war.

He distinguished himself, both as a doctor and by helping on deck during battles. Rodney appointed him physician to the fleet. With the authority of this position, he required the ships’ doctors and military hospitals in the region to submit monthly reports enumerating the illnesses and deaths among sailors of the fleet. These reports became the basis of his later writing and his efforts to affect naval policy.

Why did he believe that collecting such data would be useful? No one had ever done this before, and one can only imagine the grumblings of the doctors about unnecessary paperwork. Blane wrote that his primary motive was to distribute patients and resources efficiently among the hospitals in the region. He added: “These returns [reports] have served also . . . as a method of collecting a multitude of well-established facts, tending to ascertain the causes and course of disease.”⁶

This insight is the foundation of epidemiology.

In 1781, between tours in the West Indies, Blane submitted a report, which he called a memorial, to the Admiralty. He noted that of twelve thousand men serving the fleet there had been sixteen hundred deaths, of which sixty had been due to enemy action and the remainder caused by infection and scurvy. He added:

Scurvy, one of the principal diseases with which seamen are afflicted, may be infallibly prevented, or cured, by vegetables and fruit, particularly oranges, lemons or limes. These might be supplied by employing one or more small vessels to collect them at different islands; policy, as well as humanity, concur in recommending it. Every fifty oranges or lemons might be considered as a hand to the fleet, inasmuch as the health, and perhaps the life, of a man would thereby be saved.⁷

In response, the Admiralty asked the Office for Sick and Hurt Seamen, the committee of physicians responsible for the health of the sailors, to render an opinion. Citing the experience of Captain Cook with Lind’s rob, they advised that wort and sauerkraut were much more effective than fresh fruit and vegetables. The Admiralty accepted the advice of its panel of medical experts and ignored Blane. This is an early example of how one must be wary of advice given solely based on expert opinion.

However, Blane did not lose his interest in the health of sailors, nor did he surrender to the bureaucracy. Instead, he used the temporary truce to marshal his forces.

THE FIRST EPIDEMIOLOGIST

After service in the navy, Blane returned to London to resume his medical practice. He wrote an account of his experience in the West Indies, published in 1789 as Observations on the Diseases of Seamen.⁸ It is an underrated work, possibly because it is one of the most boring books ever written. Nevertheless, it had a bigger impact on the history of scurvy and the history of medicine than Lind’s Treatise.

Blane, like Lind, was a product of the Scottish Enlightenment, but, unlike Lind, he was not locked in to conventional theories. He thought that to make progress one had to “compare a great number of facts” and not rely on individual cases or preconceived hypotheses. He was an inveterate compiler of statistics. More than a third of his textbook consists of the tables of data he collected in the West Indies. The month-by-month and ship-by-ship health statistics, along with his analysis of these tables in turgid prose, make for tedious reading.

By studying patterns of disease incidence over time, including the ships and hospitals under his supervision, Blane made inferences about the causes of diseases and how to manage them effectively. These analyses of the incidence of disease across time and space form the basis of the science of epidemiology, and Blane was the first practitioner of that science.

He was convinced that Lind had proven that lemons, limes, and oranges were the most effective antiscorbutics available. To bolster that belief, he pointed to two ships that came into port after a battle and were able to purchase limes. The men on these ships recovered from scurvy, while the disease continued to increase on the other ships of the fleet, which did not have the benefit of fresh limes.

Blane drew other conclusions with practical consequences. First, he dismissed the importance of bad air—miasma—in causing scurvy: “It was remarked, that the men recovered faster on board than on shore; and it would appear that land air, merely as such, has no share in the cure of the scurvy, and that the benefit arises from the concomitant diet, cleanliness, and recreation.”⁹ He also noted that Lind’s rob was ineffective. He blamed the heating of the juice for abolishing its antiscorbutic properties, although he did not say how he reached that conclusion.

Blane made several observations concerning the containment of contagious diseases on board ship. He went beyond Lind by using his observations to affect policy. Since hospitals at that time were incubators of infections, he kept sailors with scurvy on board ship for their treatment.

It appears that only four men died of this disease [scurvy] in the whole fleet in the month of June, though there were so many ill of it; whereas it appears by the book of hospitals, that scorbutic men die there in much greater proportion, and chiefly in consequence of other diseases, particularly the flux [dysentery], which they catch by infection, or bring on by intemperance. It is farther in favour of this scheme, that great numbers of those sent on shore are lost by desertion. It is also a great saving to the Government, the expense not being a fourth part of what it would cost in a hospital.¹⁰

Given the state of medical care in the eighteenth century, the prevention of disease, not its treatment, was Blane’s main concern.

The prevention of diseases is as much deserving our attention as their cure, for the art of physic is at best fallible, and sickness, under the best medical management, is productive of great inconvenience, and is attended with more or less mortality. The means of prevention are also more within our power than those of cure, for it is more in human art to remove contagion, to alter a man’s food and what air he is to breathe, than it is to produce any given change in the internal operations of the body. What we know concerning prevention is also more certain and satisfactory, in as much as it is easier to investigate the external causes that affect health than to develop the secret springs of the animal œconomy.¹¹

His words still resonate in the twenty-first century.

BLANE’S VICTORY

Despite being rebuffed by the Admiralty Board in 1781 when he submitted his memorial, Blane won in the end. In 1795, he was appointed commissioner to the Board of the Sick and Wounded Sailors (formerly the Office for Sick and Hurt Seamen). He gained this appointment despite being, by all accounts, personally unlikeable. Moreover, he did not mince his words. In Observations on the Diseases of Seamen, he laid the blame for sailors’ illnesses at the feet of the officers and the Admiralty.

It was a saying of some of the ancients, that acute diseases were sent from heaven, whereas chronic diseases were of man’s own creation. But I shall endeavor in the course of this work to evince, that, with regard to seamen at least, acute diseases are as much artificial as any others, being the offspring of mismanagement and neglect, with this difference, that they are imputable not so much to the misconduct of the sufferers themselves, as of those under whose protection they are placed.¹²

With his new authority, he persuaded the Lords of the Admiralty to provide, but not mandate, a dose of three-quarters of an ounce of lemon juice daily to each man. This was no longer Lind’s ineffective rob, preserved by heating, but either fresh juice or juice preserved in alcohol. Although ships’ captains did not all adopt the practice, there was a steep drop in the number of cases of scurvy in the British Navy.

This was the first example of the use of epidemiological data to guide government policy. It was a milestone in the history of medicine. Blane demonstrated that merely tabulating and analyzing when and where diseases occur can lead to better understanding of their cause and prevention, even when the disease is not contagious. The idea now seems obvious, but it had never been carried out on the scale and with the diligence of Gilbert Blane.

Most sources date the birth of the science of epidemiology to 1854, when the London physician John Snow analyzed a cholera epidemic.¹³ Snow tracked all the cases in London and pinpointed the source of the epidemic to the Broad Street pump, a source of drinking water for a London neighborhood. This was before microorganisms had been discovered as the cause of infections, but Snow persuaded the authorities to remove the pump handle. Either as a result or coincidentally, the epidemic subsided, and the Broad Street pump became famous in the annals of medicine. Snow and Blane both deserve admiration, but Blane paved the way.

Thanks to Blane, after the death of more than a million sailors over three centuries, scurvy ceased to be the primary cause of death in the British Navy. In contrast to Lind, Blane analyzed his observations dispassionately, without trying to fit them into the theories he had been taught as a medical student. Although it took almost fifteen years, he used his insights to persuade the naval bureaucracy to improve the lives of its sailors.

Blane had a remarkable ability to ignore theory and false claims and see the problem of scurvy clearly. What gave him this objectivity? There are few clues. In an unfinished portrait, he looks like an accountant, and he had an accountant’s love of numbers. He pored over the monthly reports from the fleet while he served the navy. His book spends many pages presenting the numbers and almost none discussing theories of disease.

It is equally remarkable that he was able to mold naval policy. According to one obituary, “The station attained may fairly be attributed to his talents and industry than to possession of external graces and artificial attractions.”¹⁴ He was persistent. He did not give up when snubbed by the Admiralty in 1781, but he remained interested in naval medicine and kept pressure on the bureaucrats. His prose was stilted, as was typical of his day, but clear and direct, and he knew more about his subject than anyone of his time. His victory was a triumph of careful science.

However, his success was not complete. Because the provision of antiscorbutics was not universal, scurvy did not disappear entirely from the Royal Navy. That required drastic action by the sailors themselves to give the final push to the Lords of the Admiralty.

THE ROYAL NAVY IN THE GEORGIAN ERA

Near-continuous warfare marked the reign of King George III, which extended from 1760 to 1820. Great Britain had been at war on multiple fronts: with its rebellious American colonies on one side and with European powers, primarily Napoleonic France, on the other. Additionally, Britain still had its overseas empire to defend. The navy was crucial to conflicts over much of the globe. Despite their importance to the country, British seamen not only shared the dangers and privations of all mariners during the Age of Sail, but they endured indignities unique to the Royal Navy.

As many as half of the sailors on some ships were prisoners in all but name, having been impressed into service. Impressment was the practice by which all able-bodied English mariners—merchant seamen and fishermen as well as former navy men—were subject to being drafted into the navy. Impressment was unique to Britain. Queen Anne instituted the practice in 1711 and subsequent monarchs continued it until the Napoleonic Wars ended in 1814.

Press gangs roamed the waterfront and received a bounty for each man they provided. The press gangs were authorized by law to take only experienced seamen, but in practice they took whomever they could find by any means available. They induced some men to serve voluntarily but took many by force, frequently while drunk. Many of the impressed men were old, infirm, and chronically mal-nourished. Others had just stepped ashore from their previous long voyages, still suffering the effects of months of hard labor and poor nutrition. When the need was desperate, men were taken directly from hospital wards.

Courts of law provided another source of recruits. Magistrates could sentence criminals to serve their time in the navy rather than jail. These criminals were not all illiterate thieves and muggers; some were white-collar criminals or men with unpaid debts, some were men with education, and some with experience running businesses. They formed a core group of potential leaders in the forecastle, where the ordinary seamen lived.

Common sailors still were not allowed to leave the ship when in port because of the risk of desertion. On board, they had few rights. Some of the officers were brutal. They resorted to flogging and keelhauling to maintain discipline. Captains had the authority to impose the death penalty, and sailors could be shot or thrown overboard for minor offenses.

Nevertheless, regulations required that the sailors at least have adequate food. The Victualling Board oversaw the system. Victualling officials, stationed in the ports, purchased supplies and distributed them to the ships’ bursars. The Victualling Board gave exquisitely detailed specifications for the weekly ration:

One pound avoirdupois clean, sweet, sound, well-bolted with a horse cloth, well-baked and well-conditioned biscuit; one gallon, wine measure, of beer; two pounds avoirdupois of beef killed and made up with salt in England, of a well-fed ox, for Sundays, Mondays, Tuesdays and Thursdays, or instead of beef, for two of these days one pound avoirdupois of bacon, or salted English pork, or a well-fed hog, and a pint of pease (Winchester measure) therewith; and for Wednesdays, Fridays and Saturdays, every man, besides the aforesaid allowance of bread and beer, to have by the day the eighth part of a full-size North Sea cod of 24 inches long, or the sixth part of a haberdine 22 inches long, or a quarter part of the same if but 16 inches long; or a pound avoirdupois of a well-savoured Poor John [dried fish cake], together with two ounces of butter, and four ounces of Suffolk cheese, or two-thirds of that weight of Cheshire.¹⁵

Although deficient in vitamins, this diet would have provided sufficient caloric intake to support hard physical labor and included a necessary mixture of carbohydrates, protein, and lipids.

However, in Georgian England, every level of the provisioning process was corrupt. By the time the provisions reached the sailors, they were reduced in both quantity and quality. Kickbacks, adulteration, short weights, and theft of supplies were rife. The exact constitution of the actual diet is unknown but was certainly less than prescribed by the Victualling Board.

Ships were usually provisioned for six months, and the food spoiled over time. The biscuits grew moldy and worm-infested, the beer spoiled, and the cheese and butter became rancid. Since ordinary seamen could not go ashore, they had no opportunity to supplement this diet.

The British military strategy depended on the naval blockade of enemy ports and constant patrolling of the Channel and North Sea. Ships were frequently at sea for months at a time, some only a few miles off the coast of Britain. Although it was possible to reprovision ships periodically using tenders, as suggested by Gilbert Blane, this was not done. The authorities saw this as unnecessary, as they already had supplied the ships with ample provisions and were unwilling to incur the added expense of providing fresh food.

Pay was the sailors’ number-one grievance. The continuous warfare had bankrupted the Crown, and lack of money was at the root of many of the navy’s problems. Although the army had received a recent pay raise, sailors had not received an increase in more than thirty years despite a rise in the cost of living. Some crews had not been paid for more than two years. Their only hope of reward was a share of the booty from captured enemy vessels.

Faced with these conditions, the sailors rebelled. The men of the Channel Fleet took the opportunity in spring 1797 when they anchored at England’s main naval base at Portsmouth.

THE SPITHEAD MUTINY¹⁶

At the end of March 1797 and after a month at sea, the sixteen large warships and more than twenty smaller craft of the Channel Fleet sailed into the Solent, the narrow channel between Portsmouth and the Isle of Wight on the south coast of England. They came to refit and reprovision. The country was on edge, expecting an armada of French and Dutch ships to attack any day. The navy, and especially the Channel Fleet, had to be at peak readiness to defend the islands.

They moored at Spithead, an anchorage two to three miles offshore from Portsmouth. In the distance the sailors could see the town bustling with wartime activity. The Solent was crammed with ships. In addition to the Channel Fleet, dozens of vessels filled the docks and shipyards of the huge naval base next to the town.

As Easter was only two weeks away, most officers took the opportunity to go ashore and enjoy town life or visit their families, leaving the sailors on board the closely packed ships with little supervision. Anchored in calm waters, they had a respite from their labors and could talk among themselves out of earshot of the few officers still on board. The spirit of the French Revolution was in the air, and this was an opportunity for the men to press their many grievances. If they stuck together, they had leverage, as the nation was depending on them to fend off the expected invasion. To coordinate their plans, the leaders rowed back and forth between ships, usually under the cover of darkness. They agreed to take decisive action.

On Easter Sunday the order came to sail. The men refused. In a coordinated action, they banished the officers to shore, established self-government on the ships, and refused to put to sea until the Admiralty addressed their demands. They presented their petition to the Admiralty in the form of letters signed by representatives of each ship. After asking for a raise in pay, the sailors listed their demands for better conditions on board:

We, your petitioners, beg that your Lordships will take into consideration the grievance of which we complain, and now lay before you.

First, That our provisions be raised to the weight of sixteen ounces to the pound, and of a better quality; and that our measures may be the same as those used in the commercial code of this country.

Secondly, That your petitioners request your Honours will be pleased to observe, there should be no flour served while we are in any port whatever, under the command of the British flag; and also, that there might be granted a sufficient quantity of vegetables of such kind as may be most plentiful in the ports to which we go; which we grievously complain and lay under want of.

Thirdly, That your lordships will be pleased seriously to look into the state of the sick on board His Majesty’s ships, and that they may be better attended to, and that they may have the use of such necessaries as are allowed for them in time of sickness; and that these necessaries be not on any account embezzled.¹⁷

Other demands included shore leave while in port, continuation of pay for men injured in the course of duty, and removal of brutal officers.

The naval hierarchy first ignored these demands and then obstinately refused to address them, threatening to charge the perpetrators with the capital offense of mutiny. The sailors remained steadfast. After a month, with an invasion expected any day and Parliament growing restless, the Admiralty had no choice but to address the grievances and King George to grant the mutineers a pardon.

The mutiny spread unevenly to other ships, but these did not achieve the success of the Spithead fleet. Many of those participants were executed or exiled to Australia. Because of the prevalence of scurvy on the ships ferrying prisoners to New South Wales, exile to Australia was a death sentence for many. The Admiralty did not expend resources providing fresh vegetables or lemon juice to prisoners.

The Spithead Mutiny had far-reaching consequences for the Royal Navy, even though its success was limited to the Channel Fleet. The pay for common seamen was raised, and they were allowed shore leave while in port. Officers with a record of brutality were removed, and the officer corps became more professional. The Admiralty began to pay attention to living conditions on board their ships. More attention was given to keeping the ships clean, and the navy provided the men dry clothing and bath soap. Fresh vegetables were added to the sailors’ diet, and the authorities enforced the resolution of 1795 to provide citrus juice to all the ships, a policy that to that point had been applied inconsistently.

Gilbert Blane and the ordinary seamen had won. Scurvy virtually disappeared from the Royal Navy for more than a half century. But, remarkably, not permanently.