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37 Special Feature

James Lind – the father of maritime medicine

Surg Lt J Callaghan

“To a crew replete in health, what enterprise too dangerous? What achievement too great? Whereas a sickly Ship’s Company, impotent and dispirited, have frustrated many a well-concerted expedition, and that bravery, which the enemies of our country have not been able to vanquish, has fallen a sacrifi ce to the cruel ravage of devouring disease.” , 1757.

James Lind can arguably be considered the father of maritime medicine. Born into a Scottish merchant family in 1716, his medical career began with an apprenticeship to an surgeon (1). In 1738 he joined the , serving with ships in the Mediterranean, the west coast of Africa and the West Indies. After a decade at sea, he returned to Edinburgh to complete his Medical Doctorate (specialising in venereal disease) and established himself in private practice. In 1758 he resigned from the Royal College of Physicians in Edinburgh, and took up the post of Chief Physician to His Majesty’s Royal Hospital at Haslar. By the time of his retirement twenty-fi ve years later, the hospital had grown to become one of the largest in Europe (2).

In 1757, the Royal Navy was in the midst of the Seven Years’ War. The Channel squadrons took station to protect against the threat of invasion from France. Fleets were deployed to protect British territories in the Mediterranean, the Indian Ocean and Americas (3). It was against this backdrop that Lind published ‘An Essay on the Most Effectual Means of Preserving the Health of Seamen, in the Royal Navy’ (Fig 1). It contained practical advice for Command along with recommendations for new regulations that led to improved health at sea. Figure 1. James Lind’s Essay on the health of seamen. Typhus (often from the merchant service), or drawn from local Although more famous for his work with , Lind prisons. Lind warned against bringing men from prisons deserves recognition for his efforts to combat another directly onto ships: “… there is a disease of a contagious disease that blighted ships throughout the fl eet – typhus. He nature, the produce of fi lth, rags, poverty, and a polluted addressed this in the second edition of his essay, published air, which subsists always in a greater or less degree in in 1762. As part of the war effort, the Royal Navy had crowded prisons, and in all nasty, low, damp, unventilated expanded rapidly to 71,000 men by 1759, a year called the habitations … and has been too often fatally experienced, Annus Mirabilis due to a series of naval victories (4). Many by taking such contaminated persons into our Ships.” of these men were volunteers, but others were press-ganged Typhus, a bacterial infection spread by lice, frequently J Royal Naval Medical Service 2015, Vol 101.1 38

caused epidemics of high fever, and the ‘seeds of infection’ series of recommendations to the Admiralty detailing ways were known to survive in clothing. of protecting sailors from scurvy. It was written after he started work at the newly-founded Royal Hospital Haslar If a man volunteered for service, he would be given an and was treating patients with the disease (9). He observed advance of wages to buy his uniform (‘slops’) and hammock that men press-ganged from returning merchant ships (5). Pressed men received nothing. Lind recommended were particularly vulnerable to scurvy, and recommended that slops should be issued to pressed men. He wrote: “to that: “if … those who are just arrived from a long and prevent the communication of the infection … the most sickly voyage, were directly allowed fresh provisions, and ragged and suspicious persons should remain for at least especially a sufficient quantity of greens, in lieu of salted fourteen days [on a small ship in a river] where their old and other meats, a diet of this sort continued for at least clothes might be destroyed, and new ones given them; and three weeks, would, in all probability sufficiently cleanse their persons being well purified and cleansed, they would and restore their constitution, and fit them for immediate thus be prevented from carrying rags, filth, and infection Service.” There is no evidence that this recommendation on board the King’s Ships”. He noted that woollen clothes was adopted. It was common practice for warships to harboured the infection for longer than other fabrics. In intercept inbound merchant shipping in the Channel, and 1781 the Royal Navy introduced new regulations requiring press experienced seamen into Service – these men would pressed men to be quarantined with fresh clothing and not have been landed for fear of desertion (10). bedding on reception tenders, before being allowed to join a ship of the line (6). Cleanliness of ships and naval During the Seven Years’ War, the Royal Navy maintained a hospitals improved dramatically over the next quarter of blockade of the French naval ports of Brest and Toulon. Lind a century, and the resulting improvement to the health of noted that scurvy was commonplace in the Channel fleet. sailors has been attributed to the efforts of Lind and his He advised the Admiralty of the need for a new approach contemporaries (7). to the provisioning of the ships: “One of the press-tenders might be ordered out once a fortnight from Plymouth, to Scurvy repair to the rendezvous or station of the squadron, loaded Lind’s 1753 essay, ‘A Treatise on the Scurvy’, had been with live cattle and greens, to be served to the men by the largely ignored by the Admiralty and the medical profession Purser, in lieu of their salted meats.” He believed that (8). In it, he described a he had performed on sailors would forego their meat ration for fresh vegetables: patients with scurvy when on board HMS SALISBURY “It is hardly to be supposed that any man who has the (Box 1). The results of this trial, along with an early least tendency to a scurvy, would not willingly part with a example of a systematic review of available literature, led piece of salt beef, or a pound or two of biscuit, to purchase him to postulate that fruits could be used to treat the these obvious means of health, and a reprieve from dying disease. This is arguably Lind’s greatest achievement, in of a most painful and loathsome disease.” Later in the that he advanced the concept of the randomised controlled eighteenth century, the Victualing Board commissioned trial. Lind believed that the cause of scurvy was multi- packet boats from to supply fresh vegetables to the factorial, suggesting that it was due to faulty digestion squadrons in the Channel, though it is not known if sailors and excretion, and that poor diet, foul air and lack of willingly gave up salted meats in exchange (11). exercise also contributed (1). The concept of micronutrient deficiency did not exist in contemporary thinking. Lind was an experimental scientist who put the ideas of others to the test, as well as suggesting his own solutions. In the 1762 edition of ‘An Essay on the Most Effectual Although he knew that citrus fruits could treat scurvy, it was Means of Preserving the Health of Seamen’, Lind made a impractical for ships to carry fresh fruits for long voyages

“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 the 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. … Two were ordered each a quart of cyder a day. Two others took twenty-five drops of elixir of vitriol [dilute solution of sulphuric acid] three times a day … Two others took two spoonfuls of three times a day … Two of the worst patients were put on a course of sea-water … Two others had each two oranges and one given them every day … The two remaining patients, took … an electuary [paste made up of garlic, mustard seed, dried radish root and gum myrrh] recommended by a hospital surgeon … The consequence was, that the most sudden and visible good effects were perceived from the use of oranges and ; one of those who had taken them, being at the end of six days fit for duty … The other was the best recovered of any in his condition; and … was appointed to attend the rest of the sick. Next to the oranges, I thought the cyder had the best effects …”

Box 1. An extract from A Treatise on the Scurvy. 39 Special Feature

due to spoilage. His proposal was to use ‘rob’ (a condensate describe how “tobacco smoke was conveyed to his lungs of citrus made by bringing juice near to the boil): “If through the tube of a common pipe” (18). the West Indians could fall upon a method of making such large quantities … of the rob, or inspissated juice of lemons What comes next in Lind’s essay can be seen reflected in or limes, as would reduce them to a low price, mariners contemporary Cardiopulmonary Resuscitation (CPR): “A … might then be supplied with a noble preservative of person … may endeavour to blow into the lungs with his health, in sultry unhealthful climates.” Lind never tested breath, keeping the nostrils of the patient shut for a few the effectiveness of his formulation, but others later found seconds of time, to prevent its escape: meanwhile, another it offered no protection from scurvy (now known to be as person, by a gentle alternate pressure and dilatation of the a result of the heat-labile nature of ascorbic acid) (12). In ribs, with a corresponding alternate compression of the 1795 the Admiralty began supplying lemon juice to ships at contents of the belly upwards, imitates as near as possible sea, using alcohol as a preservative (13). the act of respiration in a living body.” He emphasised to his readers the importance of continuing the resuscitation Lind also recommended that ships on long voyages grew while the patient was being warmed: “Though these means , calling it: “a powerful antidote to the scurvy”. should not speedily produce the desired effect, yet the The seeds were hardy, the cress was fast-growing and could person is not to be relinquished. They must be repeated provide a rich source of ascorbic acid (14). He commented and continued for some hours, keeping the body all the that: “in a rainy season, all the old blankets may then be while warm, or in a hot place.” When all else had failed, converted into gardens; and the whole Ship both above he recommended that the patient: “be immersed and kept and below, as also her sides, be replete with verdure [lush for some time in a bath of luke-warm water, after which, green growth].” The Royal Navy’s Board of Sick and Hurt the former means are to be again essayed”. This advice commissioned Captain Cook to look at the effectiveness is picked up by other authors of the period, with one going of this proposal during his 1772 voyage in the Pacific. as far as to recommend that the attempt should only be Cook took with him a number of remedies recommended abandoned when the body showed signs of putrefaction as being effective in treating scurvy, including , (19). malt of wort and watercress. There were few cases of scurvy, though enough for Cook to conclude that of all the Yellow fever treatments, wort “was one of the best anti-scorbutics yet Lind recognised that epidemics of fever were very common discovered” (15). Wort was later found to be ineffective, in tropical waters, but that steps could be taken to reduce and the Board of Sick and Hurt did not revisit using the risk to the ship’s company. From his time at sea he knew watercress as a potential . that the sickness was more common when ships came close in to shore in sheltered harbours, and that boats’ crews Near-drowning were often the first affected. He, in line with contemporary In an era when few sailors could swim, falling overboard thinking, believed that tropical sickness was caused by was a significant hazard. Lind made a recommendation noxious vapours from the land, and recommended that ships that: “So soon as a person supposed to be drowned is anchor “at as great a distance from the shore as can well be taken out of the water, he ought not, as usual, to be held done.” He noted: “the higher ships sail up the rivers upon up long by the heels”. He advocated that: “the head must the coast of Guinea, the more sickly they become”. Yellow be inclined in a position favourable to empty the stomach; fever epidemics along the African coast and in the West meanwhile the utmost dispatch is used to remove all the Indies caused significant loss of life in the army and Royal cold, wet clothes, by stripping the person quite naked, and Navy. Lind’s advice was applied in the West Indies where immediately exposing the body to the heat of the warm sun, captains considered it essential to remain off shore to avoid or a fire”. As part of the resuscitation, he advised that: ‘land air’ (20). As usual, Lind’s advice was appropriate but “air, moderately heated by being near the fire, [be] blown the rationale was flawed; over a century after his death, the by means of a bellows into the anus and lungs”. The use mosquito Aedes aegypti was identified as the transmission of air enemas (and, later, tobacco smoke enemas) became vector for yellow fever. increasingly common in near-drowning, though the benefits of this practice were questioned by a contemporary author Lind identified marshy areas as the most disease-ridden. If writing in 1788: “Let us examine the effects which this a ship had to anchor close in to marshland he advised that celebrated and favourite remedy produces in the animal men kept off the upper deck at dawn and dusk, and that the economy; we may then perhaps judge whether it is entitled landward gun-ports be closed at night. He advised crews to the popularity and preference it so eminently enjoys” going ashore for wooding and watering to avoid, if at all (16,17). Whether the Royal Navy promoted the use of possible, sleeping on the beach. If forced to stay ashore, enemas is not known. A near-drowning case from a ship he recommended they lay a “small fire sufficient to raise off Spithead in 1802 makes no mention of enemas but does a gentle smoke, without occasioning a troublesome heat” J Royal Naval Medical Service 2015, Vol 101.1 40

within their tent, as he had seen the natives of Guinea do. edition of the essay. Lind noted: “Having found that when Lind returned to the theme of preventative medicine in his sea-water boils, nothing ascends but a pure vapour, which 1768 work, ‘An Essay on Diseases Incidental to Europeans when condensed by any simple means, is converted into an in Hot Climates. With the Method of Preventing their Fatal excellent pure and elementary water; no persons at sea, or Consequences’. even when cast away upon a desert island where there is fuel, will now ever perish for want of fresh water, if either they carry a still to sea, or can on shore make a contrivance The other disease that concerned Lind most in the tropics for distilling simply the sea-water.” Despite the problems was “the malignant fever of the remitting or intermitting of spoilage associated with fresh water casks, the Admiralty kind” – the disease now called malaria. In his essay, he did not adopt distillation technology on a large scale until refers to a medicine called the ‘Jesuits’ Bark’ as being the age of steam. Built in 1861, HMS WARRIOR was one “universally known, by practitioners of all nations, to be of the first ships to make practical use of the technique, the only sovereign medicine for this most frequent and using steam from her boilers to supply drinking water if malignant fever, in those sickly southern climates.” This required (23). refers to the quinine-rich bark of the cinchona tree, used by Jesuit missionaries to treat malaria in Peru and brought to Conclusion European pharmacies by Jesuit merchants. Although it was In many ways the Royal Navy’s first occupational physician, well known that the bark could treat fever, Lind commented Lind noted that in peacetime a sailor’s health was likely to that it was only possible to administer the bark during an be better than his equivalent shore-side: “In times of public intermission in the fever. Rather than treating the disease, tranquillity, when only smaller Ships of War are employed, Lind wanted to prevent it – he noted that continued use and manned with sound and seasoned sailors, their cruises of it after recovery: “is an effectual preservative against or voyages short, and sufficient opportunity allowed to a relapse. Hence one would naturally infer, that the use refresh in harbour, the seamen in His Majesty’s Service are of the bark would prevent the attack of this sickness.” in general, healthy. A ship of fifty or sixty guns commonly In 1773, the surgeon aboard the Rainbow carried out his buries fewer men in three years, than most villages in own trial of the bark during a trip to the coast of Africa, England containing a like number of inhabitants.” He and administered it to men before they went ashore. The incidence of fever was much lower than on nearby ships, noted that medical care for Navy sailors was of high quality and the success of the trial was reported to the Admiralty and free, in contrast with the merchant service. Unlike in (21). The Sick and Hurt Board agreed to supply the bark to the French navy, a Royal Navy sailor did not have to deal ships deployed to West Africa, though for the next 30 years with a stoppage of pay when admitted to hospital. Lind it resisted demands for bark to be supplied to West Indian understood that pensions were important: “Nor is it a ships, believing that the risk of fever was lower there and small additional pleasure to a seaman in the Royal Navy, that it did not warrant the high cost of a trial (22). to reflect, that whatever misfortunes … may befall him in the service of his country, he will be honourably rewarded, Drinking water and, under many circumstances of but small accident, Lind identified the provision of safe drinking water as obtain a pension for life.” important for health. When sailed on his first voyage of discovery, he took with him aboard the Acknowledgements ENDEAVOUR a piece of equipment designed by Lind. The author is grateful to Mrs Jane Wickenden for her In 1761, Lind wrote to the Royal Society with an idea for guidance on the Historic Collections Library at the Institute an apparatus that would distil fresh drinking water from of Naval Medicine, and for access to the 1762 edition of sea water, using either solar energy or heat from the ship’s James Lind’s essay. fires. The text of the letter is included within the second

References 1. Milne I. Who was James Lind, and what exactly did he achieve? J R Soc Med 2012;105:503-8. 2. Tröhler U. James Lind at Haslar Hospital 1758-1774: a methodological theorist. James Lind Library Bulletin, 2003. 3. Wilson B. Empire of the Deep: the Rise and Fall of the British Navy. Weidenfeld & Nicolson; 2013:Ch 28. 4. McLynn F. 1759: The Year Britain Became Master of the World. Pimlico; 2005:233. 5. http://www.royalnavalmuseum.org/info_sheet_impressment.htm [accessed November 2014]. 6. Gabriel R. Between Flesh and Steel: A History of Military Medicine from the Middle Ages to the War in Afghanistan. Potomac Books; 2013:103. 7. Convertito C. The Health of British Seamen in the West Indies, 1770-1806. University of Exeter; 2011:176. 8. Tröhler U. James Lind and Scurvy: 1747 to 1795. James Lind Library Bulletin, 2013. 9. Birbeck E. The Royal Hospital Haslar: from Lind to the 21st Century. James Lind Library Bulletin; 2011. 10. Hill J. The Oxford Illustrated History of the Royal Navy. Oxford University Press; 2002:135-7.