A Historical Perspective on Scar Management

Jane A. Petro

KEY POINTS

Scars are still the inevitable result of healing after tissue injury such as trauma or infection, despite new advances in wound care and injury management. Scars can also result from intentional injury as decorations or symbols of accomplishment.
Medical care has historically made substantial gains through military attempts to protect, repair, and restore personnel who are injured.
Due largely to the effectiveness of first aid on the battlefield, modern warfare has increased the likelihood of survival despite devastating injuries. This has presented new challenges to the treatment of wounds and the resulting scars, and in lifelong rehabilitation.
Scars provide evidence of injury and are important forensic signs, as well as stigmatizing deformities.

All scars tell a story. A childhood fall, an adult fight, an accident, an assault—all will leave their mark. In modern times, the elective scar of a surgical incision has gone from the large heroic scars (the bigger the better) of general surgery, to the carefully planned, minimally invasive incisions of modern times. Once the sign of a great surgeon, the prestigious elective scar is now the nearly invisible scar. The contributions of war-related medical advances represent an important chapter in medical history. Survival from the complex blast/burn/bullet injuries of modern weapons is nearly assured and provides new challenges for recovery. Thus, the history of scars, from ancient wounds to the horrendous scars that signify survival from grievous injury, tells the story of not only human resilience, but of medical miracles.

Scars result from healing without regeneration through the deposition of collagen and fibrous connective tissue. Why the salamander can regenerate a leg and other tissue, but a human cannot, is an evolutionary conundrum. A common laboratory regeneration model is the Mexican axolotl (Fig. 1-1). This endangered species regenerates entire limbs as well as nervous tissue. Mammals are known for some specific regenerative capacities, like antlers in the deer family, which are shed and regrown annually. Humans may be able to regenerate the endometrium, liver, and kidney, but only minimal segments of fingers or toes. In general, humans heal after injury by the formation of scar tissue as a means of bridging the defect, whether it involves only skin or larger chunks of skin muscle and bone.

What is the evolutionary advantage of healing by scar versus regeneration? Energy requirements for wound healing in humans are well documented. For a simple femur fracture, the bedridden patient who normally requires 2,500 calories per day may require up to 6,000 calories per day.¹ Burns, in particular, result in high caloric requirements during recovery and are significant scar-forming injuries.² Burns involving less than 20% of the total body surface and wartime amputations were frequently fatal until nearly the end of the 19th century, and only slightly larger burns until well after 1950. The relative efficiency in time and energy requirements for scar healing compared to regeneration after major injury is likely an evolutionary advantage for the species, if not for the modern individual.

As the complex biology of wound healing becomes increasingly understood, greater insights into the modulation of healing and vertebrate regeneration are emerging. Genetic manipulation in one mouse species has even restored regenerative capacity. The Lin28a gene, silenced in maturing vertebrates, restores regenerative ability when turned on in mouse infancy, but not in maturity.³ Another species, the African spiny mouse, can heal full-thickness skin injuries without scarring. Current intensive research on the use of stem cells for regeneration is widespread, as are clinical practices promoting their use, despite limited documentation in controlled clinical trials. The identification of the Lin28a and b genes and their role in stem cell regeneration is also being rapidly elucidated.⁴ These concepts offer the promise of future transformative approaches to healing human tissues.

Scars are destined to become part of medical lore if the full potential of current research on genetic manipulation, embryonic healing, and stem cell applications is achieved.
The management of scars to date has depended on the prevention of injury, the optimization of wound healing, and the direct treatment of scars after they have formed. This chapter will explore the progress in scar care through history, as well as the meaning scars have had in medicine, law, and literature. So many different individuals have contributed to our knowledge of wounds, their management, and the diagnosis and treatment of scars that not all of them can be introduced in this chapter. Table 1-1 provides an outline of the more important events in the years preceding the modern era of wound care and scar management. I have chosen not to focus on events of this modern era. Rather, I have offered my own view of some of the key people and events prior to the last 60 years. More recent advances are the province of other authors in their respective chapters.

FIGURE 1-1 Axolotl (Ambystoma mexicanum). A: Three varieties. B: Amputation of a limb. C: Complete regeneration. (Images courtesy of the Monaghan Lab at Northeastern University.)

Scars from Injury and for Identification

Early human history documents a variety of wounds treated in specific ways. Guido Manjo, in his encyclopedic treatment of the history of wounds, The Healing Hand, identified several such early nonfatal as well as fatal wounds.⁵ One example involves a pre-Columbian arrowhead found in Patagonia, penetrating the sternum and assumed to be fatal. In another, a prehistoric arrowhead embedded in the tibia and sealed in place provides evidence of successful healing. Wound fatality, even in earliest times, seems a matter of chance, luck, and random fate. The fossil record has identified both a fatal injury (skull fracture) and the weapon (a humerus) in an australopithecine man. There is even evidence of healing in this skull fracture, so the injury was not immediately fatal.⁶

Manjo describes in great detail the nature of injuries and their treatment in sources as disparate as the Ebers Papyrus; ancient Chinese, Indian, and Arabic texts; as well as Greek and Roman literature. While more interested in wounds than in scars, Manjo has extracted from among the scraps of writing dating from the Egyptian-Greek period descriptions of individuals who are recognized by their scars⁵:

Charetos, one-scar-small-finger-right-hand; Maron, eldest son of Omnephreus, aged 40, with a scar on his forehead; his brother Omnophresu, born of the same father, with no marks.

These descriptions appear in documents related to contracts, identifying the signatories at a time when last names were not used. The use of physical features including scars

continued throughout multiple eras. In the later 19th century, the French developed the Bertillon System of individual identification. This system applied extremely detailed anthropometric measurements, accompanied by photographs and descriptions of scars and birthmarks, as part of the means of identifying unique individuals. In the United States, the military and the penal systems adopted variations of Bertillon’s System in 1887. Additionally, the Surgeon General in December 1888 required that “all soldiers be vaccinated on the outer aspect of the left leg at a point 4 inches below the head of the fibula, and that every man be so vaccinated when enlisted or reenlisted.” In this manner the vaccination scar distinguished a soldier from a civilian. The use of other identifying characteristics was employed to enable ready identification of those who had been discharged dishonorably, or convicted of a crime. This was particularly directed at preventing unwanted reenlistments. The earlier system, with its careful measurement of “length of the figure, measurements of the outstretched arms, length and width of the head, of the right and left ear, left foot, middle and little finger and left forearm” was abandoned in favor of detailed descriptions of any identifying marks, their location, and only then the height of the individual. The practice of vaccination on the leg was abandoned in 1891 when it became apparent that there was a high rate of temporary disability associated with inflammation.⁷ In 1889, the Army adopted a simpler method of identifying soldiers using standardized cards (Figs. 1-2 and 1-3). Note on the chart that a tattoo is also used for identification.

Table 1-1 Historic Discoveries in Wound Healing and Scar Management

Name	Nationality	Attribution Date	Life Dates	Accomplishment
Heironimus Brunschwig	German	1497	1450-1512	Advocated careful suturing of facial wounds to minimize infection
Leonardo Botallo	Italian	1560	1519-1587	Recommended NOT using boiling oil on gunshot wounds
Ambroise Pare	French	1575	1510-1590	Strongly advocated use of wound dressings of egg yolk, turpentine, and oil of roses
				Wrote first encyclopedic text on treatment of battlefield injuries
				Collected works, “Les Oeuvers,” became the cannon of military surgery
Gaspare Tagliacozzi	Italian	1597	1545-1599	Developed “distant flap” and wrote detailed textbook
Wilhelm Fabry von Hildend	German	1614	1560-1624	Classification of burns into 3 categories Recommended splinting to prevent contraction
Cesare Magati	Italian	1637	1579-1647	“What heals the wound is nature not the physician or his medicines”
				Advocated moist dressings only
Gentleman’s Magazine	English	1794		Published description of the “Indian Flap” (forehead) of Sushruta for nasal reconstruction
Fraincois Chopart	French	1799	1743-1795	First description of a pedicle flap to reconstruct the lip
Sir Humphrey Davey	English	1799	1778-1829	Discovered nitrous oxide, but used it only as a party trick, not anesthesia
Guiseppe Baronio	Italian	1804	1758-1811	Through experimental surgery, using sheep, showed that skin grafting was effective
Dominique Jean Larrey	French	1812	1766-1842	Advanced standardized military medical care of the sick and wounded regardless of rank
				“Flying ambulances”
Jean-Louis Ailbert	French	1806	1768-1873	Clearly described keloids as a specific type of scar
Joseph C. Carpue	French	1816	1764-1846	Promoted the use of flaps, influencing von Graef, Delpech, and others
Astley Cooper	English	1817	1768-1841	First recorded description of a successful skin graft
Johann Frederick Dieffenbach	Prussian	1827	1794-1847	Wrote on tissue transplantation and regeneration Considered the founder of plastic surgery
Ernst Carl Friedrish Blasius	German	1833	1802-1875	Nasolabial flaps
John Mason Warren	American	1840	1811-1867	First recorded documentation of a full-thickness skin graft
William T. G. Morton	American	1846	1819-1868	Popularized the use of ether anesthesia
James Young Simpson	Scottish	1847	1811-1870	Introduced chloroform for human use first at a dinner party and then obstetrics a few days later
Oliver Wendell Holmes	American	1855	1809-1894	Incidence of Puerperal Fever reduced from 10% to 3% by careful handwashing with calcium chlorate
Louis Pasteur	French	1857	1822-1895	Discovery of the role of bacteria in fermentation and disease
Ignaz Semmelweis	Hungarian	1861	1818-1865	Recognized iatrogenic disease transmission and promoted hand washing
Karl Langer	Austrian	1861	1819-1887	First described his idea of the lines of least skin tension using cadavers
Paul Bert	French	1865	1833-1886	First description of autograft, heterograft and homograft
Joseph Lister	English	1867	1827-1912	Antisepsis, advocated carbolic acid, required staff in OR to change gowns Noted that chronic ulcers, when closed by skin grafts, did not contract
Jaques Louis Reverdin	French	1869	1842-1928	Partial-thickness skin grafts of very small size (pinch grafts)
JohannFriedrich von Esmarch		1870	1823-1908	Standardized military medical wound care, triage, priority by severity, not rank
George Lawson	English	1870	1831-1903	First clinical description of a full-thickness graft
Louis Zxavier Ollier	French	1872	1830-1900	Successful grafting of large sheets of skin (2-4 cm²), successfully reducing scarring
Bernard Rudolph von Langenbeck	German	1874	1819-1888	Bilateral transposition flaps
John Reissberg Wolfe	Scottish	1875	1824-1904	Popularized full thickness skin grafts including dermis, but not fat
Carl Thiersch	German	1886	1822-1895	First clinical description of harvest and application of a split-thickness graft Recommended salicylic acid rather than carbolic acid for antisepsis
Harold Gilles	New Zealand	1917	1881-1960	Ran first medical hospital dedicated to facial injuries Credited as being the first modern plastic surgeon
Vilray Papin Blair	American	1920	1871-1975	Special knife for harvesting split-thickness skin grafts
Ivan Magill	Irish	1921	1888-1986	Colleague of Gilles, developed safe modern anesthesia for head and neck surgery Invented the endotracheal tube, Magill forceps, of laryngoscope, closed-circuit anesthesia system
Graham Humby	English	1934	1909-1970	Special knife with guard for setting thickness of skin graft harvest
Earl C. Padgett	American	1937	1893-1946	Invented the Padgett Dermatome, first equipment to harvest reliable, adjustable-thickness skin grafts
Harry M. Brown	American	1948	1914-1948	Electric power-guarded adjustable dermatome

The last half of the 19th century saw the slow adoption of other means of identifying personnel. A military identification system using inscribed wooden tags appeared during the Chinese Taiping revolt (1851 to 1866).⁸ During the American Civil War (1861 to 1865), combatants often pinned notes to their coats, or stenciled their name and address on their backpack. Not until the Franco-Prussian war of 1879 did the military issue “dog tags,” so called for the “hundemarken” required of dogs in Berlin at the same time. In 1907 the British replaced their identity cards with identity discs, including name, rank, and regimental information. Dog tags continued to help reveal soldiers lost in battle during World War II, as well as Vietnam.⁹ While the dog tags may still be attached on or near remains, DNA testing has been used to confirm identity since the Department of Defense began the practice in 1991 as part of the Gulf War effort.¹⁰ Thus, the use of scars for identification is supplanted now by the use of individual genetic material.

Beyond a means of identification, in some cultures scars are used as decorative adornment. This has been recognized as a common practice in sub-Saharan Africa, and recently reviewed in the medical context.¹¹ The authors note the variety of techniques including the specific tools and substances applied to achieve controlled and predictable results. Figure 1-4 depicts an example of tribal scars. Kelman Cohen, in his early research on abnormal scarring, often speculated in conversation on the value of studying intentional scarification as a means of better understanding the nature of healing in accidental scars, and Cohen raised the question of how tribal scarification seemed to avoid keloid formation (Conversations with Dr. K. Cohen in 1978, 1979 at the Plastic Surgery Research Council meetings).

History of the Medical Descriptions of Scars

Scars are described in documents as ancient as the Smith Papyrus, but medical interest in scars has evolved primarily
during the past two centuries. “Normal” scars are those that heal under optimal conditions. This requires that the wound be clean, the wound edges are aligned properly, and that healing proceeds by primary intention. Wounds that are irregular, contaminated, and have significant tissue loss and/or heal by secondary intention often result in unsatisfactory scars. In addition, unacceptable scars may result from seemingly trivial insults (including incidental scratches or acne in some individuals) or even result during healing from well-planned and executed surgical incisions. Keloids have been considered more common in certain anatomical areas, such as the presternal or deltoid regions and have (wrongly) been considered more common among dark-skinned individuals. Pathological scars are variously described as normal, atrophic, hypertrophic, or keloidal. Several of these conditions can even be seen in the same healed scar. Pathological scars attract the most medical attention, especially those that are either keloidal or hypertrophic, and/or are causing contraction across a joint.

FIGURE 1-2 US Army identification card adopted in 1889 showing the frontal view with name, military organization, height, hair and eye color, etc. and indicating placement of various marks, scars, and tattoos.

The earliest clear medical description of abnormal scars is attributed to a French dermatologist Jean-Louis-Marc
Alibert. He described certain scars in 1806 in one of the first comprehensive dermatologic texts.¹² Alibert¹³ was a believer in classification and ordered his dermatology descriptions along the lines of botany, dividing skin disorders into families, genera, and species. He later renamed one type of scar as a “cheloide” in a paper published in 1817 (Fig. 1-5). Scars that are heavily pigmented or reddened, and extend beyond the original boundaries of injury (keloids) seem to attract the most attention in this early literature. Hypertrophic scars, those that are red and raised but confined to the zone of injury and improve over time, have a more unclear documentation. There continues to be confusion between hypertrophic and keloid scars throughout the medical literature. Up until the end of the 19th century, most scar literature relates either dramatic surgical miracles, single case reports, or dermatologic descriptions. Not until the end of the 19th century does a true clinical science of scars begin to appear.

FIGURE 1-3 US Army identification card adopted in 1889 showing the posterior view indicating placement of various marks, scars, conditions, and other traumatic injuries.

FIGURE 1-4 Benin Natitingou, April 20, 2005. Man with tribal scarification on his face. Scarification is used as a form of initiation into adulthood, beauty, and a sign of a village, tribe, and clan. (Used with permission from Jean-Clajot Photography. http://www.jmclajot.net/.Accessed November 11, 2016.)

In addition to descriptions of scars, a literature on their correction began to appear in the 1800s. Earlier surgical procedures to correct deformities, such as Tagliacozzi and the “Indian” flaps, were not originally used for scars but to rebuild missing parts, mostly the nose. The use of skin flaps to correct the contractures and deformities of burns and other injuries had its origins in Germany and France. Edward Zeis (1807 to 1868) was a surgeon/ophthalmologist and collector of medical information. In 1813 he published Handbuch der plastischen Chirurgie, considered to be the first comprehensive textbook on plastic surgery. Zeis followed this with two publications collecting all the known references in the field, Die Literatur und Geschichte der plastische Chirurgie in Leipzig in 1863, with a supplement in 1864. This important work was made available in English by Frank McDowell with the publication of the Zeis Index and History of Plastic Surgery 900 BC to 1863 AD.¹⁴

FIGURE 1-5 Front page of Alibert’s naming of a particular scar as a keloid.

Interest in plastic surgery, as applied to scars as well as to defects, was apparent in both France and Germany around the time of Zeis’ plastic surgery text. Johann Friedrich Dieffenbach (1794 to 1847), considered one of the earliest facial plastic surgeons, wrote about the use of skin flaps on the face to repair the nose, referring to this as “sideways shifting.”¹⁵

Hundreds of American physicians visited Europe as part of their medical training, a requirement to be considered “well educated.” Thomas Mutter, a Philadelphia physician, spent a year studying medicine and surgery in Paris in 1831 and would have been aware of the work of Zeis and Dieffenbach, and possibly even that of von Langenbeck, another early expert in flaps. His principal surgical exposures were with Guillaume Dupuytren (1777 to 1835) at the Hotel-Dieu and Jacques Lisfrank de St. Martin at the Hopital de la Pitie. Both men wrote and performed surgery as public exhibitions, and it is known that Mutter paid special attention to “les operations plastiques.” There is a disagreement between French and German scholars whether skin flaps as used in these operations were first employed by the German or the French surgeons mentioned above. Dieffenbach was known to visit and work with Lisfrank (1790 to 1847), where Mutter would have been exposed to the ideas of both the German and French surgical schools who shared their knowledge through both writing and direct teaching. Mutter returned to Philadelphia determined to practice with the same skill he had witnessed in Paris, as well as a desire for fame like those of his mentors in Europe.¹⁶

A decade after he returned from Paris, Mutter¹⁷ published a successful case report of his treatment for burn scars of the neck. In this paper he describes the “monsters” (a common term at the time for any deformity, especially of the face) he encounters (Fig. 1-6), and tells how these women sustained burns from clothing catching fire while cooking. This type of severe burn is still seen in the developing world (Fig 1-7). Mutter described his own horror at these deformities and was determined to correct them using a flap of skin moved from unburned skin of the back. He goes into great detail describing the technique he uses to prepare the patient for this operation, without the use of anesthesia. This included multiple preoperative visits, educating the patient about the details of the surgery, massage of the operative sites, and establishing a mutual desire for success. The surgery was undertaken in an amphitheater with many observers, first incising the scar and releasing the contracture, then raising the skin flap from the back and rotating it into the
defect, closing both wounds with sutures. Despite a brief postoperative infection, the operation was apparently successful. His publication received wide notice, including reports in Europe,¹⁸ and contributed to his rising fame in Philadelphia. Mutter continued to do such procedures but never published a case series. Similar procedures are sporadically reported during the rest of the 19th century, but did not become used regularly until the 20th century as surgeons such as Sir Harold Gillies began performing reconstructive surgery as part of the World War I effort.

FIGURE 1-6 Mutter’s case 1 showing a neck contracture treated with scar release and skin flap taken from the back. (Published July 1843 in “Cases of Deformity From Burns Successfully Treated by Plastic Operations.” Philadelphia, PA: Merrihew & Thompson Printers.)

FIGURE 1-7 Contracture of the neck following a thermal burn. (Photo courtesy of Peter R. Shumaker, MD.)

The “Zeis Index” lists 44 unique reports related to scars in the medical literature through 1863. Volume II in this series, the “Patterson Index,” extends the list of references from 1864 to 1920.¹⁹ This work includes 227 references on keloids, 38 related to scars, 72 articles on scar cancer, and 71 on scar treatment. This relative explosion of interest includes recognition of different kinds of scars, and applications of nonsurgical (radiation, cautery, compression, electricity) and surgical treatments (skin grafts, flaps, relaxing incisions, needling).

The most comprehensive of all the papers in the Patterson Index related to scars appears in 1893, “Hypertrophies and degenerations of Cicatrices and Cicatricial Tissue.”²⁰ Written by John Collins Warren, Jr., this work continued a tradition of Warrens in Boston as surgeons and innovators. He was the great grandson of John Warren, a Revolutionary War hero, surgeon, and one of the founders of Harvard Medical School; the grandson of John Collins Warren, also a professor of surgery at Harvard who is best remembered for his role in performing the first surgery done under general anesthesia in 1848; and the son of Jonathan Ma-son Warren, a surgeon who was considered to be the best
cleft palate surgeon of his era, and author of a paper vastly improving the operation first described by Dieffenbach.²¹ John Collins Warren, Jr. was personally acquainted with Lister and was an early advocate of surgical asepsis, becoming the first surgeon to perform intra-abdominal surgery at Massachusetts General Hospital in 1889.

Warren’s paper on scars produced one of the first recognizably “modern” review articles. He describes in detail a variety of elements including the formation of scar tissue, the presence of atypical twisted fibers, changes in microscopic appearance and vascular composition over time, the differences seen between primarily and secondarily healed wounds, the differences between true and false keloids (probably hypertrophic scars), the histology of striae, scar contractures, and the way in which childhood scars develop as the patient grows. Warren then reports on three cases of painful surgical scars, and identifies neuromas within the scars. Throughout the article he refers to other authors of papers written in English, German, and French.

Warren also discusses keloids and his personal successful treatment of ear lobe keloids by surgical removal, and goes on to support the use of compression as part of scar management. He concludes his discussion with a report of the successful treatment of hypertrophic burn scars by the use of Thiersch grafts: “The subject of grafting opens up a fruitful field of research in connection with the surgical treatment of cicatrices, but the limits of this paper do not permit of more than a passing allusion to it.” By the end of the 19th century, descriptions were available for scar formation, the range of scar types, and both surgical and nonsurgical treatment options, including many that are still used today.

FIGURE 1-8 Date about 500 bc Achilles tending Patroclus’ wounds from a red-figure kylix (drinking vessel) in the Staatliche Museum, Berlin. (From https://upload.wikimedia.org/wikipedia/commons/b/ba/Akhilleus_Patroklos_Antikensammlung_Berlin_F2278.jpg. Accessed November 11, 2016)

The study of the basic biology of wound healing and scar formation began in the 20th century. Research into various aspects of scar formation and mitigation including the biochemical composition of collagen and their ratios in various types of scars; the role of the myofibroblast; detailed studies of growth factors, RNA, and DNA; and the expanded role of procedures including skin grafts, flaps, and even transplantation of limbs and the face have altered our understanding of scars and improved our ability to manage them. These topics are beyond the scope of this chapter and may be covered elsewhere in the text (see Chapters 5, 6, and 12).

The Scars of War

He who desires to practice surgery must go to war.

—Hippocrates

In the Iliad, Homer describes nearly 150 distinct wounds including entrance and exit points, various weapons (sword, arrow, lance), internal injuries, and the differences between fatal and nonfatal injuries. The treatment of these wounds is well illustrated in many surviving Greek urns (Fig. 1-8). Greek and Roman generals traveled with private physicians but the troops, as illustrated in this and many other urns, treated each other. A later illustration of the wounds seen before the introduction of gunpowder is well illustrated in the “Wound Man” (Fig. 1-9).

Many variations on this image appeared in surgical texts from the 1400s to the 1600s. The introduction of gunpowder changed the nature of the injuries and scarring from war and encouraged the formal introduction of military surgeons for all troops, not just officers. Ambroise Paré (1510 to 1590) was among the first physicians to be identified as a military surgeon serving under several French kings for nearly 30 years beginning in 1536. Paré seems to have been a keen observer, noting that using boiling oil on fresh gunshot wounds was less effective than simply bandaging the wound with egg yolk, turpentine, and rose oil.²² He also notes that his method caused less suffering as well as less damage to the tissues. He recommended ligation of arteries during amputations rather than cautery with a hot iron. His accounts of the treatment of gunshot wounds provide descriptions of the first interventions that were more likely helpful than harmful, in contravention to the standard practices of that time. Less well known, Paré is also credited with designing prostheses for both upper and lower limbs, as well as ocular prostheses that he formulated out of gold, glass, porcelain, and silver.²³,²⁴

Scar breakdown is one sign of scurvy, a condition that became a serious impediment to naval exploration. Vasco da Gama lost two-thirds of his crew during his 1499 voyage to India. A British expedition to the South Seas in the 1740s lost 1,300 sailors (out of the original 2,000) as well as six of their seven ships. Richard Walter, chaplain on this expedition, describes: “Skin black as ink, ulcers, difficult respiration, rictus of the limbs, teeth falling out and perhaps most revolting of all a strange plethora of gum tissue sprouting out of the mouth, which immediately rotted and lent
the victim’s breath an abominable odor.”²⁵ It is estimated that scurvy killed nearly 2 million sailors between 1500 and 1800. There are numerous accounts of the military consequences of scurvy affecting naval forces, including that of the Spanish Armada in 1588, whose defeat by the English set the stage for British dominance in the coming centuries.²⁶ James Lind (1716 to 1794), a British Naval surgeon, is often described as the “discoverer” of the fact that citrus fruit prevented and cured scurvy. His famous experiment with 12 sailors who had the disease is often acclaimed the original clinical trial, first published in 1753. This myth is thoroughly debunked by Michael Bartholomew through a close reading of Lind’s own work.²⁷ Historical research demonstrating that scurvy continued to affect middle-class Victorians and the Scott expedition at the beginning of the 20th century additionally challenges the persistent tale of how the British Navy became “Limey’s.”²⁸

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