The Third Edition of the Treatise

Stewart CP (1953) The Third Edition of the Treatise LIND’S TREATISE ON SCURVY A Bicentennary Volume containing a reprint of the First Edition of A TREATISE OF THE SCURVY by James Lind, M.D. with Additional Notes EDITED BY C. P. STEWART, Ph.D., D.Sc. AND DOUGLAS GUTHRIE, M.D. F.R.C.S.E Book reviews of the 1953 version https://doi.org/10.1056/NEJM195310012491410 https://doi.org/10.1001/jama.1953.03690150096035 https://doi.org/10.1113/expphysiol.1953.sp001028 Links to the original versions of Lind’s Treatise are at the end of this document. The Foreword to the Bicentennary Volume: https://zenodo.org/doi/10.5281/zenodo.10604636 This is a copy of the 1953 publication, pp.361-368, to make the text more widely available. This is located at: https://doi.org/10.5281/zenodo.10604738 Another series of publications to honour the 200-year anniversary of Lind’s Treatise was in the Proceedings of the Nutrition Society. The contents of the special issue: https://www.cambridge.org/core/journals/proceedings-of-the-nutrition-society/issue/ B5C5B1FF2F5E8592C93785E85D6DE286 Digitized in 2024 by Harri Hemilä, University of Helsinki, Finland https://www.mv.helsinki.fi/home/hemila https://orcid.org/0000-0002-4710-307X 1 THE THIRD EDITION OF THE TREATISE By C. P. STEWART THE third edition of the Treatise (now become A Treatise on the Scurvy) was published in London in 1772, improved, as the author says in the Advertisement, ‘by the knowledge and experience acquired from an almost constant attendance … on patients afflicted with the scurvy’. During some of these years at Haslar, while the war with France raged (1758-63), Lind might see ‘three or four hundred scorbutic patients in a day’, and every morning furnished him with ‘original pictures of the disease, in all its various forms and stages, in patients brought from all quarters of the globe’. The results of all these clinical observations and of a large number of autopsies are summarised in a Postscript which is the most important part of the new material incorporated in the third edition. Some minor alterations have been made in the original text, a few footnotes have been added and, in a supplementary chapter to Part II, accounts are given of recent outbreaks of scurvy in various parts of the world, notably during the campaigns in America. Lind’s views remained substantially unchanged, however, except in relation to the great ‘putrefaction’ he had previously supposed to be a regular feature of scurvy. More important, his outlook remained that of the scientist, always seeking for a solid foundation of fact and distrustful of unsupported conjecture. ‘It is indeed not probable,’ he says, ‘that a remedy for the scurvy will ever be discovered, from a preconceived hypothesis; or by speculative men in the closet, who never saw the disease, or who have seen, at most, only a few cases of it.’ The summaries of published works on scurvy (Part III of the Treatise) are brought up to date, and for bibliographical 2 p.362 completeness the titles of these publications are added here: 1755. A treatise on the scurvy. Designed chiefly for the use of the British navy. By Charles Bisset. 1761. Tractatus de scorbuto, Joannis A Bona. 1761. Verhande lingen Vitgegeevin door de Hollandsche Maatschappy der Weetenschappen te Haarlem. By Solomon de Monchy. 1764. Oeconomical and medical observations, in two parts, from the year 1758, to the year 1763, tending to the improvement of military hospitals, and to the cure of camp diseases, &c. By Richard Brocklesby. Page 301, Of the scurvy among soldiers. 1764. Experimental essays, &c. &c. By David Macbride. Essay IV. On the scurvy, with a proposal for trying new methods, to prevent, or cure the same at sea. 1764. An account of the diseases which were most frequent in the British military hospitals in Germany, from January, 1761, to the return of the troops to England in March, 1762. By Donald Monro. Page 250, Of the scurvy. 1764. Ludovici Rouppe, M. D. de morbis navigantium liber, sect. 2, cap 2, de scorbuto. 1766. Essai sur les maladies qui attaquent le plus communement le gens de mer, &c. Chap. 2d, On the scurvy. (Anon.) 1767. Traite des maladies des gens de mer. Par M. Poissonnier Desperrieres. Chap. 1st, Of the scurvy. 1767. An historical account of a new method of treating the scurvy at sea, containing ten cases, which shew that this destructive disease may be easily and effectually cured without the aid of fresh vegetable diet. By David Macbride, M.D. 1768. Versuch, uber auserlesene Mittel, &c. Or, A translation into the German language of an Essay on preserving the health of seamen, by Dr. James Lind; as also an abndgrnvnt of a treatise on the Scurvy, by the same author; with annotations on that treatise, by John Christian Lange. 1768. Libellus de natura, causa, curationeque scorbuti. Auctore Nathaniele Hulme, M.D. Fo which is annexed a proposal for preventing the scurvy in the British Navy. 1769. Practical thoughts on the prevention and cure of the scurvy. Especially in the British Navy. By William Jervey, M.D. A footnote to one of these summaries is interesting as affording almost the only instance of Lind’s showing any resentment at his work being overlooked. He writes: 3 p.363 ‘This [M. Poissonnier Desperrieres] is not the person, who claimed in France the discovery of freshening sea water by a simple distillation, three years after the discovery had been made by me in England’. He was quite capable, however, of having a sly ‘dig’ at an author who failed to quote his authorities. Thus of A Bona’s Tractatus de scorbuto Lind remarks that the book ‘is properly a commentary on Van Swieten’s commentary on what Dr Boerhaave has published on the scurvy’. And in a footnote he adds, ‘ It appears from some passages in this book, that Doctor A Bona had seen the first edition of my treatise on the Scurvy, wherein the distinctions made … by Boerhaave are criticized.’ The first section of the Postscript deals with Lind’s own post-mortem examinations of patients who died of scurvy. Some of his observations, on which he laid great stress, could have been made only by one who had followed his own precept—that ‘the operator should be thoroughly conversant with the usual appearance of dead bodies in general, and endeavour carefully to distinguish the effects of diseases from their causes, as also from the changes that may happen after death or in articulo mortis …’ Thus, after describing the widespread extravasation of blood into the tissues and joints, and discussing the probability that pain in scurvy is caused by these ‘extraordinary effusions of stagnated blood … being seated on parts endued with an exquisite sensation’, he concludes: ‘In a word, the true scorbutic state, in an advanced stage of the disease, seems to consist in numerous effusions of blood into most parts of the body, superficial as well as internal, particularly into the gums and legs. This is frequently, though not always, accompanied with a dropsical indisposition, which appear[s] chiefly in the legs and breast.’ To-day the hæmorrhagic tendency seems an obvious feature of severe scurvy but Lind adds a more subtle observation. After noting that, especially in the legs and thighs, the muscular fibres were often so ‘lax and tender’ that dissection was extremely difficult, he records a similar occasional ‘laxness’ of the intestinal musculature and continues: ‘Why the scurvy should so frequently, and in so singular a manner, affect the cartilages of the ribs, so as sometimes to separate 4 p.364 them altogether from their connexion with the breast-bone; and why it seats itself so commonly in the joint of the knee, I own I am at a loss to account for; otherwise, than that most diseases have their peculiar seat in the human body’. The interest of these remarks is twofold. Firstly they show Lind to have been a remarkably acute and accurate observer, with a flair for picking out the important facts and distinguishing them from the casual or incidental. Secondly, they emphasise the features of scurvy which follow from the only physiological function as yet definitely known (as the result of modern research) to be possessed by vitamin-C— that of assisting in the formation of collagen. Lack of collagen, a necessary consequence of vitamin-C deficiency, leads inevitably to deficient formation of connective tissue, bone and tooth, as well as to loss of integrity of the blood vessel walls and therefore to extravasation of blood. In this section, and also in the third, where he insists on the normal appearance and coagulability of the blood of scorbutic patients, Lind is at pains to correct his previous view that scurvy is essentially a disease of ‘putrefaction’, not on theoretical grounds but on the basis of his increased practical experience. The consideration of the ‘effects of the scurvy on other diseases’ in the second section of the Postscript affords the author an opportunity of pointing out that there is no such thing as a ‘scorbutic fever’, although patients suffering from scurvy are, like anyone else (but possibly more so), susceptible to intercurrent infection. After mentioning remarkable symptoms which have been ascribed to scurvy he protests: ‘It were indeed to be wished, that authors would be more careful not to obtrude upon the public, as the offspring of the scurvy, such uncommon and singular cases, as are very different from the true nature of this disease, or at most, are only complicated with it, and proceed from causes entirely different from those of the scurvy’. Lind points out that an infectious fever superimposed on scurvy often produces a partial remission of the scorbutic symptoms but that the recession of the fever is usually followed by a ‘return of the scurvy, with redoubled violence’. The causes of scurvy form the subject of Section IV. In the Treatise itself Lind had emphasised diet as the ‘occasional cause of the disease’ (i.e. the immediate cause), but had also 5 p.365 pointed out the importance of predisposing causes such as confinement and lack of exercise, bad living conditions, overwork, exposure, poor health, etc. He returns to this theme and points out that these predisposing causes may be so potent as to cause the appearance of scurvy even among ‘such as live on fresh greens, vegetables, or the most wholesome diet, and in the purest air’. Such attacks of scurvy are usually relatively mild: ‘All persons who have been long pent up in ships and prisons are subject to this disease. Even such as have lived on the most wholesome vegetable food, during a confinement of six or seven months, in a ship, are, after their enlargement, often sensible of a degree of weakness, which, upon an exertion of the body, particularly on walking abroad in the fields, affects them with a stoppage in the breast, or a difficulty in breathing; this is the true scorbutic lassitude and dyspnœa. Many officers of the ships of war, after long cruises at sea, came on shore in this condition, having also their legs and thighs discoloured, and spotted; to whom the disease would perhaps have proved fatal, if the free use of wine and fermented liquors, together with a vegetable and wholsome diet, had not checked its progress. ‘But, when the several causes productive of the scurvy, act with combined and uninterrupted force, it then becomes a most dreadful distemper. It reduces the most stout and vigorous constitution to the weakness of a child; and the bloom and strength of youth, to the imbecillity of age. The feeble knees tremble, and cannot support the weight of the body; nor the back, the weight of the trunk. By walking a few steps, the sick are out of breath, and often faint away; the countenance, the whole appearance, the groans, and complaints of the patients, denote the most piteous and abject state of weakness and of misery.’ In this reiteration and development of the views expressed in the original Treatise Lind is actually describing what is nowadays called the ‘stress syndrome’, of which more will be said in the Note on the metabolism of vitamin-C. It says much for his scientific acumen that he was so ready to distinguish clearly between the immediate and the predisposing causes of scurvy, to realise that the presence or absence of the disease was determined by the interaction of the causative factors and to conclude that most diseases ‘sometimes prevail 6 p.366 where their usual causes do not subsist, and at other times are not to be met with where these causes are real and apparent, which it must be owned renders this investigating branch of medical science often difficult and abstruse’. ‘To what has already been said of the virtues of oranges and lemons in this disease,’ says Lind in opening Section V of the Postscript, ‘I have now to add, that in seemingly the most desperate cases, the most quick and sensible relief was obtained from lemon juice; by which I have relieved many hundred patients, labouring under almost intolerable pain and affliction from this disease, when no other remedy seemed to avail …’ He strongly recommends adding wine (itself an antiscorbutic) and sugar. He agrees, however, that other substances (apart from fresh vegetables) are valuable antiscorbutics: scurvy-grass, juice tapped from the coconut tree, orange peel, chamomile flowers, infusion of fir or pine tips and, curiously, peruvian bark (which must be given ‘in substance, and in large quantities’); he has also a good word to say for infusion of malt. Instructions are given for treating various distressing symptoms which may accompany severe scurvy, though these are always considered as adjuncts to the use of antiscorbutics proper. Lind goes on to point out that scurvy ‘is also often relieved by the most simple means’. This passage, which clearly demonstrates Lind’s awareness of the important part played by stress and emotion in both the ætiology and the cure of scurvy, deserves to be quoted in full. ‘I have read,’ he says, ‘and heard, many relations of men supposed to be dying of this malady, who were said to have been perfectly recovered by being carried on shore to feed on the grass, to smell the earth, and by such like means. ‘These relations are not altogether destitute of truth; the following may be depended upon. ‘In the year 1761, when the English fleet lay at Belleisle on the coast of France, the men in his Majesty’s ships were preserved from the scurvy by the seasonable supplies of greens, sent from England. But the seamen in the transports had not this benefit. The owners of those ships furnished their crews with no greens or fruits whatever. Hence they became in general very much afflicted with the scurvy. Many of those unfortunate persons, labouring under this severe evil, and utterly destitute of proper remedies, were 7 p.367 carried on shore, and after being stript of their cloaths, were buried in a pit dug in the earth (the head being left above the ground) their bodies were covered over with the earth, and permitted to remain thus interred for several hours, until a large and profuse sweat ensued. After undergoing this operation, many who had been carried on men’s shoulders to those pits, were of themselves able to walk to their boats; and what was very extraordinary, two of them who had been quite disabled by this disease recovered so perfect a state of health, that they soon after embarked for the West Indies, quite recovered and in good spirits, without once tasting any green vegetables.* * Lind's footnote: ‘This is said to have been a common practice among the Buccaneers in the West Indies, when their men were afflicted with the scurvy; which brings to my remembrance the following relation, given me by a friend. ‘One day hunting in Newfoundland, he discovered, what appeared to him at a distance, to be a number of graves, with a man’s head fixed to each. Struck with the novelty of the sight, he went to the place; where he was further surprised to find the men alive; they informed him they belonged to a ship which lay in the road, and, that having been reduced to unspeakable misery by the scurvy, they were thus interred in order to obtain a cure. Was not the climate of Newfoundland too cold for this operation ?’ ‘I have myself seen many instances of patients brought into Haslar hospital, who by being only on shore for a few days, seemed surprisingly relieved, and have frequently observed, that this disease, when proceeding solely from a long continuance at sea, is strongly and suddenly influenced by the passions of the mind, and other circumstances attending the sick. The joy of being landed after a long cruise or voyage; the pleasing prospect of a speedy relief from distress, a change of air and weather, even the warmth of a comfortable dry bed, added to the efficacy of outward applications, seemed to operate powerfully and surprisingly upon this disease. ‘In the course of my experiments on patients in the scurvy, I have relieved some in such circumstances, by the most trifling prescriptions; and am persuaded, that entire credit may be given to the relation of cures similar to this published by Vander Mye, and other authors of unquestionable veracity. ‘Whether such relief was owing to the faith of the patients 8 p.368 in the extolled efficacy of the prescription, to exercise, or an enlargement after being confined in a ship, prison, or bed of sickness, or to a removal from a cold damp place to a dry and warm habitation, and in some instances to a respite from hard labour and fatigue; or lastly, to circumstances unknown or unobserved, I cannot say. It is not improbable, that many of these operated jointly towards that effect.’ It is fitting to conclude this outline of the additions which Lind saw fit to make to his Treatise after twenty years’ study in his own words. No commentator’s paraphrase could more aptly convey Lind’s scientific caution and his achievement. ‘Many diseases have been well known, and accurately described for above a thousand years; yet, for which of them have we an infallible remedy. What medicine can counteract the continued influences of improper diet, air, and confinement: the last of which in particular, I now judge to be a principal cause, of the great obstinacy and frequent mortality of the scurvy in long voyages at sea. ‘It is perhaps the vain and chimerical belief of the existence of a never failing remedy for most diseases, which occasions the quick disgust conceived to a medicine at every disappointment, and the daily attempts after new methods of cure, which has rendered the art of healing as variable and unconstant, as our dresses; which through all ages, and in most countries, are, and have been different. ‘It would indeed be happy for mankind, if in all the various calamities and distresses, to which they are subject, the means of relief were so well ascertained, as they are in this painful disease [scurvy], an ignorance of the nature of which, has long been productive of fatal consequences.’ 9