The symptoms of vitamin C deficiency. 1. Observations and descriptions by Hess, Lind, Trotter and Blane.

The symptoms of vitamin C deficiency. 1. Observations and descriptions by Hess, Lind, Trotter and Blane. Harri Hemilä, MD, PhD Department of Public Health, University of Helsinki, Helsinki, FINLAND. [email protected] https://www.mv.helsinki.fi/home/hemila https://orcid.org/0000-0002-4710-307X The primary purpose for this document was to collect data about the symptoms of scurvy by authors who were most familiar with it in the old times. Secondarily, the purpose was to collect early descriptions that fruit and vegetables – primarily oranges and lemons – are beneficial against scurvy. Links to texts are added to the extent they were identified. This PDF contains the ODF format of the text embedded so that it can be opened with LibreOffice if there is preference to a different layout or removal of the yellows. If there are further versions, they will be available through the link below. Version 1, 2024-2-20 Location of this file: https://doi.org/10.5281/zenodo.10685195 1 Contents Page Background 3 Strengths and limitations of the descriptions of scurvy symptoms by early authors 9 Alfred Fabian Hess (1875-1933) 16 Scurvy: Past and Present (1920) 19 James Lind (1716-1794) 42 A Treatise of the Scurvy in Three Parts (1753/1757/1772) 48 Thomas Trotter (1760-1834) 117 Observations on the Scurvy (1786/1792) 120 Medicina Nautica (1779/1804) 127 Sir Gilbert Blane (1749-1834) 141 Observations on the Diseases of Seamen (1785/1789/1799) 144 Elements of Medical Logick (1819/1821/1825) 148 Select dissertations on several subjects of medical science (1822/1833) 149 Recent books on scurvy 151 2 Background The classical widely known symptoms of scurvy include swelling and bleeding of the gums and poor healing of wounds. However, scurvy has a wide diversity of other symptoms outside of those classical symptoms. Meta-analyses have shown that vitamin C has effects on infections [1-7], on the cardiovascular system [8-11], and on the lungs [6,7,12-15]. Unfortunately, there is a large number of misleading and flawed papers on vitamin C and therefore it is not easy to draw valid conclusions from the large set of publications available [16-66]. The primary purpose of this document was to collect descriptions of scurvy symptoms from major early monographs on scurvy. Physicians who treated hundreds of scurvy patients had extensive direct experience about the range of symptoms that are caused by scurvy. Dyspnea, in particular dyspnoea on exertion, can be explained by effects of vitamin C on the heart or lungs or both. Edema and dropsy may indicate heart failure. Irregular pulse indicates arrhythmia. Diarrhoea and pneumonia were common in scurvy patients and they can be explained by the effects of vitamin C on the immune system. A secondary purpose of this document was to extract descriptions about the benefits of oranges and lemons against scurvy. Yellow is used to mark the sections of the old texts that are more relevant for the purposes of this document. Nevertheless, much longer sections were extracted in most cases so that the reader can see the wider contexts of the more relevant sections. 3 References 1. Hemilä H, Chalker E. Vitamin C reduces the severity of common colds: a meta-analysis. BMC Public Health. 2023;23(1):2468. https://doi.org/10.1186/s12889-023-17229-8 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc10712193 2. Hemilä H, Chalker E. Bias against vitamin C in mainstream medicine: examples from trials of vitamin C for infections. Life (Basel). 2022;12(1):62. https://doi.org/10.3390/life12010062 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8779885 3. Hemilä H, Carr A, Chalker E. Vitamin C may increase the recovery rate of outpatient cases of SARSCoV-2 infection by 70%: reanalysis of the COVID A to Z randomized clinical trial. Front Immunol. 2021;12:674681. https://doi.org/10.3389/fimmu.2021.674681 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8141621 4. Hemilä H. Vitamin C and infections. Nutrients. 2017;9(4):339. https://doi.org/10.3390/nu9040339 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5409678 5. Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2013;2013(1):CD000980. https://doi.org/10.1002/14651858.cd000980.pub4 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8078152 6. Hemilä H. Vitamin C supplementation and common cold symptoms: factors affecting the magnitude of the benefit. Med Hypotheses. 1999;52(2):171-8. https://doi.org/10.1054/mehy.1997.0639 https://hdl.handle.net/10138/223761 7. Hemilä H, Louhiala P. Vitamin C for preventing and treating pneumonia. Cochrane Database Syst Rev. 2013;(8):CD005532. https://doi.org/10.1002/14651858.cd005532.pub3 https://hdl.handle.net/10138/225862 8. Hemilä H, Louhiala P. Vitamin C may affect lung infections. J R Soc Med. 2007;100(11):495-8. https://doi.org/10.1177/014107680710001109 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2099400 9. Rozemeijer S, Hemilä H, van Baaren M, de Man AME. Vitamin C may reduce troponin and CKMB levels after PCI and CABG: a meta-analysis. BMC Cardiovasc Disord. 2023;23(1):475. https://doi.org/10.1186/s12872-023-03459-6 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc10512653 10. Hemilä H, Chalker E, de Man AME. Vitamin C may improve left ventricular ejection fraction: a meta-analysis. Front Cardiovasc Med. 2022;9:789729. https://doi.org/10.3389/fcvm.2022.789729 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8913583 11. Hemilä H, Suonsyrjä T. Vitamin C for preventing atrial fibrillation in high risk patients: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2017;17(1):49. https://doi.org/10.1186/s12872-017-0478-5 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5286679 12. Juraschek SP, Guallar E, Appel LJ, Miller ER. Effects of vitamin C supplementation on blood pressure: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2012;95(5):1079-88. 4 https://doi.org/10.3945/ajcn.111.027995 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3325833 13. Hemilä H. The effect of vitamin C on bronchoconstriction and respiratory symptoms caused by exercise: a review and statistical analysis. Allergy Asthma Clin Immunol. 2014;10(1):58. https://doi.org/10.1186/1710-1492-10-58 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4363347 14. Hemilä H. Vitamin C may alleviate exercise-induced bronchoconstriction: a meta-analysis. BMJ Open. 2013;3(6):e002416. https://doi.org/10.1136/bmjopen-2012-002416 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3686214 15. Hemilä H. Vitamin C and common cold-induced asthma: a systematic review and statistical analysis. Allergy Asthma Clin Immunol. 2013;9(1):46. https://doi.org/10.1186/1710-1492-9-46 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4018579 16. Hemilä H. Divergence in mortality at 5 days is overlooked by Adhikari et al. (2023) in a trial on vitamin C for COVID-19 patients. Pubpeer Jan 2024. https://pubpeer.com/publications/38194670B815AEE6450D922AA405E2#2 17. Hemilä H, Chalker E. Abrupt termination of vitamin C from ICU patients may increase mortality: secondary analysis of the LOVIT trial. Eur J Clin Nutr. 2023;77(4):490-4. https://doi.org/10.1038/s41430-022-01254-8 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc10115628 18. Hemilä H. Erroneous data in a meta-analysis on vitamin C and the common cold. PubPeer 2023 Sep. https://pubpeer.com/publications/447CAC9813A0D535D018047143870A#1 19. Hemilä H, Chalker E. Assessment of vitamin C effects on pneumonia and COVID-19 using Mendelian randomization: analysis may be misleading. Eur J Clin Nutr. 2022;76(9):1347–8. https://doi.org/10.1038/s41430-022-01091-9 20. Hemilä H, Chalker E. Vitamin C and the risk of atrial fibrillation: Mendelian randomization study may be misleading. Clin Nutr. 2022;41(6):1446-7. https://doi.org/10.1016/j.clnu.2022.04.029 https://hdl.handle.net/10138/569672 21. Hemilä H, Chalker E. Vitamin C and the risk of cardiovascular diseases: Mendelian randomization study may be misleading. Eur J Prev Cardiol. 2022;29(9):e291-e292. https://doi.org/10.1093/eurjpc/zwac067 https://hdl.handle.net/10138/569671 22. Hemilä H. Statistical problems in the vitamin C trial with PCI patients by Shafaei-Bajestani et al. (2019). Pubpeer 2022 Feb. https://pubpeer.com/publications/1B59AD863839D55215841C1124C2D3#1 23. Hemilä H. Statistical problems in the vitamin C trial with CABG patients by Moludi et al. (2020). Pubpeer 2022 Feb. https://pubpeer.com/publications/2E9E504061A7DC2AF6B2692D8632F1#1 24. Retracted. Extra dose of vitamin C based on a daily supplementation shortens the common cold: a meta-analysis of 9 randomized controlled trials. Biomed Res Int. 2023;2023:9848057. https://doi.org/10.1155/2023/9848057 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc10110384 25. Hemilä H. Shortcomings in the vitamin C and common cold meta-analysis by Ran. (2018) Pubpeer 2021 Mar. https://pubpeer.com/publications/077EAB95E9141BE6A455C30F0A688E#1 [This led to the retraction in 24.] 5 26. Hemilä H. Gültekin (2021) paper has a substantial number of identical data with the 20-year earlier Demirag (2001) paper. 2022 Feb. https://pubpeer.com/publications/8150B66EC0289FA4BF7C9ADB1C48A9#1 27. Hemilä H, Chalker E. Vitamin C and zinc lozenges for COVID-19? J Am Pharm Assoc (2003). 2021;61(5):e39. https://doi.org/10.1016/j.japh.2021.05.018 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8163692 28. Hemilä H, Carr A. Comment on ‘Therapeutic target and molecular mechanism of vitamin C-treated pneumonia: a systematic study of network pharmacology’ by, Li R, Guo C, Li Y, Liang X, Yang L, Huang W. Food Funct., 2020, 11, 4765. Food Funct. 2021;12(3):1371-2. https://doi.org/10.1039/d0fo02189j 29. Hemilä H, Chalker E. Commentary: vitamin C supplementation for prevention and treatment of pneumonia. Front Med. 2021;7:595988. https://doi.org/10.3389/fmed.2020.595988 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7854566 30. Hemilä H, Chalker E. Commentary: the long history of vitamin C: from prevention of the common cold to potential aid in the treatment of COVID-19. Front Immunol. 2021;12:659001. https://doi.org/10.3389/fimmu.2021.659001 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8047412 31. Hemilä H. Flaws in the inclusion of trials and in referring to earlier meta-analyses. 2021 Jan. https://pubpeer.com/publications/3C3BC7155720D6313E0A0EB6091A7B#1 32. Hemilä H, Chalker E. Reanalysis of the effect of vitamin C on mortality in the CITRIS-ALI trial: important findings dismissed in the trial report. Front Med (Lausanne). 2020;7:590853. https://doi.org/10.3389/fmed.2020.590853 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7575729 33. Hemilä H, Chalker E. Vitamin C for cardiac surgery patients: several errors in a published meta-analysis. Comment on “Effects of vitamin C on organ function in cardiac surgery patients: a systematic review and meta-analysis. Nutrients 2019, 11, 2103”. Nutrients. 2020;12(2):586. https://doi.org/10.3390/nu12020586 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7071442 34. Hemilä H. Cochrane has not consistently followed the COPE guidelines. Eur J Clin Invest. 2020;50(4):e13216. https://doi.org/10.1111/eci.13216 https://hdl.handle.net/10138/326823 35. Hemilä H. Statistical problems in the vitamin C and common cold trial with South Korean army recruits. BMJ Mil Health. 2020 Apr. https://militaryhealth.bmj.com/content/168/2/117.responses 36. Hemilä H. Random-effects assumption in meta-analyses. JAMA. 2019;322(1):81. https://doi.org/10.1001/jama.2019.5439 https://hdl.handle.net/10138/312604 37. Hemilä H. Misleading review on vitamin C and cardiac patients. 2019 May. https://pubpeer.com/publications/DEBED5D9F498A0C940E18841C25C75#1 38. Vorilhon P, Arpajou B, Roussel HV, Merlin É, Pereira B, Cabaillot A. Retraction note: efficacy of vitamin C for the prevention and treatment of upper respiratory tract infection: a meta-analysis in children. Eur J Clin Pharmacol. 2021;77(6):941. https://doi.org/10.1007/s00228-021-03150-9 https://pubmed.ncbi.nlm.nih.gov/33988724 6 39. Hemilä H, Chalker E. Vitamin C and the common cold in children: severe flaws in the meta-analyses by Vorilhon (2019). 2021 https://hdl.handle.net/10138/333365 https://doi.org/10.5281/zenodo.6395732 [This led to the retraction in 38.] 40. Hemilä H, Chalker E. Meta-analysis on vitamin C and the common cold in children may be misleading. Eur J Clin Pharmacol. 2019;75(12):1747-8. https://doi.org/10.1007/s00228-019-02733-x https://hdl.handle.net/10138/318103 See also supplement: https://doi.org/10.5281/zenodo.6395644 41. Hemilä H. Errors in a meta-analysis on vitamin C and post-operative atrial fibrillation. Int J Surg. 2019;64:66. https://doi.org/10.1016/j.ijsu.2019.01.025 https://hdl.handle.net/10138/312582 42. Hemilä H. Publication bias in meta-analysis of ascorbic acid for postoperative atrial fibrillation. Am J Health Syst Pharm. 2017;74(6):372-373. https://doi.org/10.2146/ajhp160999 https://hdl.handle.net/10138/312602 43. Hemilä H. Erroneus calculation of sample size in a vitamin C and atrial fibrillation trial. J Cardiol. 2017;69(6):895. https://doi.org/10.1016/j.jjcc.2016.10.010 44. Hemilä H. Vitamin C in clinical therapeutics. Clin Ther. 2017;39(10):2110-2. https://doi.org/10.1016/j.clinthera.2017.08.005 https://hdl.handle.net/10138/228957 45. Hemilä H. Thomas Chalmers, vitamin C and the common cold. J R Soc Med. 2016;109(2):46. https://doi.org/10.1177/0141076815606279 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4793763 46. Hemilä H. Zinc lozenges and vitamin C for the common cold are not examples of placebo effect in action. J Clin Epidemiol. 2015;68(12):1524-5. https://doi.org/10.1016/j.jclinepi.2015.05.012 https://hdl.handle.net/10138/228079 47. Hemilä H. Vitamin C and exercise-induced bronchoconstriction: further problems in the Cochrane review “vitamin C for asthma” (2012). 2013 https://doi.org/10.5281/zenodo.6405803 https://hdl.handle.net/10138/40816 48. Hemilä H, Al-Biltagi M, Baset AA. Retraction: Vitamin C and asthma in children: modification of the effect by age, exposure to dampness and the severity of asthma. Clin Transl Allergy. 2012;2(1):6. https://doi.org/10.1186/2045-7022-2-6 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3320558 49. Hemilä H. Vitamin C and community-acquired pneumonia. Am J Respir Crit Care Med. 2011;184(5):621-2. https://doi.org/10.1164/ajrccm.184.5.621a 50. Hemilä H. The effect of vitamin C on the common cold. J Pharm Pract. 2011;24(2):241-2. https://doi.org/10.1177/0897190010392376 51. Hemilä H. Randomised trials on vitamin C. Br J Nutr. 2011;105(3):485-7. https://doi.org/10.1017/s000711451000351x 52. Hemilä H. Vitamin C for the common cold should not be rejected on the basis of old and erroneous articles. J Allergy Clin Immunol. 2009;124(4):859. https://doi.org/10.1016/j.jaci.2009.06.015 7 53. Hemilä H. Spectacular reduction in the mortality of acutely injured patients by the administration of vitamins C and E and selenium. JPEN J Parenter Enteral Nutr. 2009;33(4):447-8. https://doi.org/10.1177/0148607108328520 https://hdl.handle.net/10138/16985 54. Hemilä H. Evidence-based medicine and the role of antioxidants in physically stressed people. Nutr Rev. 2009;67(1):61-3. https://doi.org/10.1111/j.1753-4887.2008.00134.x 55. Hemilä H. Feedback on: Kaur B, Rowe BH, Arnold E. Vitamin C supplementation for asthma. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000993. 2009 https://doi.org/10.5281/zenodo.6405775 https://hdl.handle.net/10138/296440 56. Hemilä H. The role of vitamin C in the treatment of the common cold. Am Fam Physician. 2007;76(8):1111, 1115. https://www.aafp.org/pubs/afp/issues/2007/1015/p1111a.html 57. Hemilä H. Small trials focusing on surrogate end points may be uninformative. Eur J Appl Physiol. 2007;99(6):707-8. https://doi.org/10.1007/s00421-006-0387-2 58. Hemilä H. Vitamin C and exercise-induced immunodepression. Eur J Clin Nutr. 2007;61(10):1241-2. https://doi.org/10.1038/sj.ejcn.1602751 https://hdl.handle.net/10250/135144 59. Hemilä H. The effect of nutrition on exercise-induced immunodepression. Nutr Rev. 2006;64(10 Pt 1):476-7. https://doi.org/10.1111/j.1753-4887.2006.tb00179.x 60. Hemilä H. The protective effect of vitamins a and C on endotoxin-induced oxidative renal tissue damage in rats. Tohoku J Exp Med. 2006;208(2):99-100. https://doi.org/10.1620/tjem.208.99 61. Hemilä H. Echinacea, vitamin C, the common cold, and blinding. Clin Infect Dis. 2005;41(5):762-3. https://doi.org/10.1086/432629 62. Hemilä H. Vitamin C supplementation and common cold symptoms: problems with inaccurate reviews. Nutrition. 1996;12(11-12):804-9. https://doi.org/10.1016/s0899-9007(96)00223-7 https://hdl.handle.net/10250/7979 63. Hemilä H. Vitamin C, the placebo effect, and the common cold: a case study of how preconceptions influence the analysis of results. J Clin Epidemiol. 1996;49(10):1079-84. https://doi.org/10.1016/0895-4356(96)00189-8 https://hdl.handle.net/10250/8082 64. Hemilä H, Herman ZS. Vitamin C and the common cold: a retrospective analysis of Chalmers' review. J Am Coll Nutr. 1995;14(2):116-23. https://doi.org/10.1080/07315724.1995.10718483 https://hdl.handle.net/10138/42358 65. Hemilä H. The good and harm of vitamin C. Nutrition Today 1994;29:49-50. https://doi.org/10.1097/00017285-199403000-00008 https://hdl.handle.net/10250/135155 66. Hemilä H. Vitamin C, cholesterol, and the nutritional recommendations. Am J Cardiol. 1993;71(5):503-4. https://doi.org/10.1016/0002-9149(93)90498-2 https://hdl.handle.net/10138/225880 8 Strengths and limitations of the descriptions of scurvy symptoms by early authors Strengths of the early descriptions of scurvy symptoms Scurvy is rare nowadays. Few current physicians treat more than a single scurvy patient during their career, and the great majority do not treat any cases of scurvy. However, in some contexts in history scurvy was frequent, particularly during long sea voyages. Observations in such contexts provide relevant information about the range of scurvy symptoms. There were other diseases bothering sailors such as infections which sometimes made a substantial proportion of the sailors acutely sick when the ships landed on tropical islands with swarms of mosquitoes. However, when sailors started to suffer from scurvy during long continuous travels over oceans – without any landings – it is likely that most of such disease burden was homogeneously scurvy. Furthermore, the rapid recovery of sailors with oranges and lemons also strongly indicates that the disease was scurvy and not a series of other diseases. James Lind (1716-1794) described his own experience in treating scurvy patients as follows: The pages refer to the 1953 bicentennial 1st edition of the Treatise (in parenthesis: pp. in the 3rd ed) p.59-63 (3rd p.36-40) It may be believed, that there are few people who have had the opportunities of reading more upon this subject than I have done ; and that there are few books or observations published upon the disease, that have not fallen under my inspection… (3rd p.iii-vi) This treatise now makes its appearance in a third edition, improved by the knowledge and experience acquired from an almost constant attendance for thirteen years, on patients afflicted with the scurvy. Though the disease has of late raged with great mortality in different parts of the world, as will appear from the Supplement, yet perhaps, no spot whatever has exhibited more numerous or more distressing cases of it than Haslar hospital1 : I here frequently visited, during five years of the late war with France [from the year 1758 to 1763], three or four hundred scorbutic patients in a day ; every morning furnished me with original pictures of the disease, in all its various forms and stages, in patients brought from all quarters of the globe : on comparing these with accounts of authors, I found the disease to be precisely the same in every age, and in every country. (3rd p.114) As the appearances on the skin in such as are afflicted with the scurvy are numerous and various, I shall in this third edition, attempt to class all the different spots, or eruptions on the surface of the body, which I have remarked in many thousand scorbutic patients at Haslar hospital. (3rd p.504-505) I have remarked among some thousand patients in Haslar hospital, that such as were scorbutic, were not liable to be seized with fevers and that even an infection from a fever was long resisted by a scorbutic habit of body… I have examined the cases of several thousand scorbutic patients, who had been sent from different ships, in order to find, whether any other fever was commonly attendant on the scurvy, than what has been already mentioned. 1 Haslar hospital. https://www.royalhaslar.com/history https://en.wikipedia.org/wiki/Royal_Hospital_Haslar https://www.jameslindlibrary.org/articles/the-royal-hospital-haslar-from-lind-to-the-21st-century 9 Alfred Fabian Hess (1875-1933) Alfred Hess appears to be the most important clinical researcher on scurvy in the early part of the 20th century. There was extensive biochemical research related to scurvy which led to the identification of vitamin C and to the Nobel prize to Albert Szent-Györgyi in 1937; however, SzentGyörgyi was not a committed long-term scurvy researcher and not a clinician. In 1920, Hess wrote a monograph, which is informative about the clinical aspects of scurvy. On the following pages are extracts of the monograph by Hess that are relevant about the symptoms. Portrait of Alfred Fabian Hess: https://www.facebook.com/StrausHistoricalSociety/photos/a.172141832916264/2286596761470750 https://dp.la/item/081485fa1faf59ee801a66301939f799 https://siarchives.si.edu/collections/siris_arc_393647 Biographies about Alfred F Hess: Bass MH. Alfred Fabian Hess (1875-1933). Semin Pediatr Infect Dis. 2005;16(2):144-7. https://doi.org/10.1053/j.spid.2005.01.003 Wiedemann HR. The pioneers of pediatric medicine. Alfred Fabian Hess (1875-1933). Eur J Pediatr. 1993;152(6):461. https://doi.org/10.1007/bf01955048 Rosen G. The case of the consumptive conductor, or public health on a streetcar: A. centennial tribute to Alfred F. Hess, MD. Am J Public Health. 1975;65(9):977-8. https://doi.org/10.2105/ajph.65.9.977 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1775957 Darby WJ, Woodruff CW. Alfred Fabian Hess-a biographical sketch (October 9, 1875–December 5, 1933). J Nutr. 1960;71:3-9. https://doi.org/10.1093/jn/71.1.1 Bass MH. Alfred Fabian Hess (1875-1933). J Pediatr. 1955;46(6):731-7. https://doi.org/10.1016/s0022-3476(55)80182-5 Collected writings. Ann Intern Med 1936;10(4):558. https://doi.org/10.7326/0003-4819-10-4-558 Jobling JW, Park WH, Cohn AE. Alfred Fabian Hess. Bull N Y Acad Med. 1934;10(1):44-9. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1965595 Gerstenberger HJ. Alfred Fabian Hess, M.D. Am J Dis Child. 1934;47(3):635-9 https://doi.org/10.1001/archpedi.1934.01960100161022 Alfred Fabian Hess. Science 1934;79:70-2. https://doi.org/10.1126/science.79.2039.70 https://www.jstor.org/stable/1660244 https://archive.org/details/sim_science_1934-01-26_79_2039/page/70/mode/2up https://en.wikipedia.org/wiki/Alfred_Fabian_Hess 16 Identified papers on scurvy by Hess: Hess AF. Diet, Nutrition and Infection. N Engl J Med 1932; 207:637-48. https://doi.org/10.1056/NEJM193210132071501 Hess AF. Recent advances in knowledge of scurvy and the antiscorbutic vitamin. JAMA 1932;98(17):1429-33. https://doi.org/10.1001/jama.1932.02730430005002 Hess AF, Weinstock M. The catalytic action of minute amounts of copper in the destruction of antiscorbutic vitamin in milk. JAMA 1924;82(12):952-6. https://doi.org/10.1001/jama.1924.02650380020007 Hess AF. Nutritional disorders in the light of recent investigations. Boston Med Surg J 1922;187:101-108. https://doi.org/10.1056/NEJM192207201870303 Hess AF. The Vitamines. Am J Public Health (N Y) [book review]. 1922;12(9):782. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1354242 Hess AF. The Vitamines. Am J Public Health (N Y) [book review]. 1922;12(5):430–1. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1354134 Hess AF, Unger LJ. The destruction of the antiscorbutic vitamin in milk by the catalytic action of minute amounts of copper. Proc Soc Exp Biol Med. 1921;19(3):119-20. https://doi.org/10.3181/00379727-19-57 https://www.biodiversitylibrary.org/item/156400#page/129/mode/1up Hess AF, Unger LJ. The destructive effect of oxidation on antiscorbutic vitamine. Proc Soc Exp Biol Med. 1921;18(5):143. https://doi.org/10.3181/00379727-18-68 https://www.biodiversitylibrary.org/item/156421#page/153/mode/1up Hess AF, Unger LJ. Scorbutic beading of the ribs. Am J Dis Child. 1920;19(5):331-6. https://doi.org/10.1001/archpedi.1920.01910230001001 https://doi.org/10.5281/zenodo.10102674 Hess AF, Unger LJ. The deleterious effect of the alcalization of infant’s food. JAMA 1919;73(18):1353-6. https://doi.org/10.1001/jama.1919.02610440033012 Hess AF, Unger LJ. Infantile scurvy. VIII. Factors affecting the antiscorbutic value of foods. Am J Dis Child. 1919;17(4):221-40. https://doi.org/10.1001/archpedi.1919.04110280002001 Hess AF, Unger LJ. The scurvy of guinea pigs: III. The effect of age, heat, and reaction on antiscorbutic foods. J Biol Chem. 1919;38:293-303. https://doi.org/10.1016/S0021-9258(18)87356-2 Hess AF, Unger LJ. The rôle of fat-soluble vitamine in the dietary of infants. Proc Soc Exp Biol Med. 1919;17(3):49-50. https://doi.org/10.3181/00379727-17-28 https://www.biodiversitylibrary.org/item/156393#page/59/mode/1up Hess AF, Unger LJ. The effect of heat, age and reaction on the antiscorbutic potency of vegetables. Proc Soc Exp Biol Med. 1919;16(4):52-3. https://doi.org/10.3181/00379727-16-32 https://www.biodiversitylibrary.org/item/156391#page/62/mode/1up Hess AF, Unger LJ. The scurvy of guinea pigs: II. Experiments on the effect of the addition of fruits and vegetables to the dietery. J Biol Chem. 1918;35:487-96. https://doi.org/10.1016/S0021-9258(18)86442-0 17 Hess AF, Unger LJ. The scurvy of guinea pigs: I. The experimental dietary. J Biol Chem. 1918;35:479-86. https://doi.org/10.1016/S0021-9258(18)86441-9 Hess AF. Focal degeneration of the lumbar cord in a case of infantile scurvy. J Infect Dis. 1918;23(5):438-42. https://www.jstor.org/stable/30084324 https://archive.org/details/jstor-30084324/mode/2up Hess AF, Unger LJ. Canned tomatoes as an antiscorbutic. Proc Soc Exp Biol Med. 1918;16(1):1-2. https://doi.org/10.3181/00379727-16-1 https://www.biodiversitylibrary.org/item/156391#page/11/mode/1up Hess AF, Unger LJ. Experiments on antiscorbutics. Report of an antiscorbutic for intravenous use. Proc Soc Exp Biol Med. 1918;15(8):141-2. https://doi.org/10.3181/00379727-15-193 https://www.biodiversitylibrary.org/item/156397#page/151/mode/1up Hess AF, Unger LJ. Experiments on the scurvy of guinea pigs. Proc Soc Exp Biol Med. 1918;15(6):82. https://doi.org/10.3181/00379727-15-158 https://www.biodiversitylibrary.org/item/156397#page/92/mode/1up Torrey JC, Hess AF. The relation of the intestinal flora to the scurvy of guinea pigs and of infants. Proc Soc Exp Biol Med. 1918;15(5):74-8. https://doi.org/10.3181/00379727-15-154 https://www.biodiversitylibrary.org/item/156397#page/84/mode/1up Hess AF. Infantile scurvy. V. A study of its pathogenesis. Am J Dis Child. 1917;14(5):337-53. https://doi.org/10.1001/archpedi.1917.01910110018002 Hess AF. Subacute and latent infantile scurvy: the cardiorespiratory syndrome (a new sign). JAMA 1917;68(4):235-9. https://doi.org/10.1001/jama.1917.04270010235001 https://doi.org/10.5281/zenodo.10102042 Hess AF. Infantile scurvy. III. Its influence on growth (length and weight). Am J Dis Child. 1916;12(2):152-65. https://doi.org/10.1001/archpedi.1916.04110140045007 https://doi.org/10.5281/zenodo.10102854 Hess AF. Cardiorespiratory involvement in infantile scurvy. Proc Soc Exp Biol Med. 1916;14(1):4-5. https://doi.org/10.3181/00379727-14-3 https://www.biodiversitylibrary.org/item/156376#page/14/mode/1up Hess AF. Infantile scurvy. II. A new aspect of the symptomatology, pathology and diet. JAMA 1915;65(12):1003-6. https://doi.org/10.1001/jama.1915.02580120015005 https://doi.org/10.5281/zenodo.10102476 Hess AF, Fish M. Infantile scurvy: the blood, the blood-vessels and the diet. Am J Dis Child. 1914;8(6):385-405. https://doi.org/10.1001/archpedi.1914.02180010395001 https://doi.org/10.5281/zenodo.10207276 Hess AF. The involvement of the blood and blood vessels in infantile scurvy. Proc Soc Exp Biol Med. 1914;11(5):130-2. https://doi.org/10.3181/00379727-11-80 https://www.biodiversitylibrary.org/item/156416#page/140/mode/1up 18 Hess AF. Scurvy: Past and Present (1920) https://www.gutenberg.org/ebooks/40505 https://www.gutenberg.org/files/40505/40505-h/40505-h.htm https://digital.library.cornell.edu/catalog/chla2903792 https://archive.org/details/cu31924073869996 https://archive.org/details/b29823778 https://archive.org/details/scurvypastpresen00hess https://archive.org/details/scurvypastpresen00hessiala https://archive.org/details/scurvypastpresen00hessuoft https://archive.org/details/39002086348019.med.yale.edu https://archive.org/details/scurvypastandpr00hessgoog https://archive.org/details/nutritionfoundat0000hess https://openlibrary.org/books/OL6631267M Book reviews: Scurvy. Past and Present. Ann Intern Med 1983;98:431. https://doi.org/10.7326/0003-4819-98-3-431_2 Scurvy: Past and Present. Nature 1921;107:713. https://doi.org/10.1038/107713d0 Scurvy Past and Present. Boston Med Surg J 1921;184:496. https://doi.org/10.1056/NEJM192105121841908 Hart CD. Scurvy: Past and Present. Am J Public Health 1921;11(4):370 https://doi.org/10.2105/AJPH.11.4.370 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1353801 19 PREFACE The World War has tended also to demand a renewed consideration of scurvy… Its incidence, however, was not limited to the military forces. Reports from England and the continental countries clearly indicate that scurvy prevailed among the civilian population during the past few years to a degree unknown in peace times. This was especially true of infants and children. For the past seven years I have been engaged in an investigation of scurvy both in the laboratory and in the clinic, and have treated various aspects of the subject in a large number of articles published in various medical journals. In the course of these studies there has been ample opportunity for a comprehensive review of the widely-scattered literature. No treatise on scurvy has been published in English since the classical work of Lind in 1772. The time, therefore, seemed opportune to gather into one volume the recent advances in this field and to offer to the clinician, to the hygienist, and to the biological chemist a presentation of the existing status of this important nutritional disease. ALFRED F. HESS. New York, August, 1920. CHAPTER I: HISTORY OF SCURVY p.1-4 It is difficult, as may be imagined, to define with precision the earliest description of scurvy, as the older references are so vague as to be open to individual interpretation… The Greek, Roman and Arabian writers do not seem to have been acquainted with scurvy. This is as we should expect, for fruits and vegetables grew in such plenty in these southern countries that scurvy must have been a disorder of rare occurrence. … An interesting early description of scurvy, and one which is quite convincing, is that of de Joinville,15 who accompanied the Crusaders in their invasion of Egypt under St. Lewis, about the middle of the thirteenth century. He refers to the lividity and spongy condition of the gums, and describes how “the barber surgeons were forced to cut away the dead flesh from the gums to enable the people to masticate their food” he describes their debility, their tendency to faint, and the black spots on their legs… It is probable that scurvy existed in the northern parts of Europe and Asia ever since they were settled by man. We should hardly expect to have records of this condition, in view of the low educational status of the people, their greatly restricted literature, and their lack of intercourse with the people in the southern countries. In the sixteenth century, with the development and spread of 15 Jean de Joinville. Saint Louis, King of France. 1249. https://archive.org/details/SaintLouisKingOfFrance/page/n97/mode/2up https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5403999 (p.59-60) https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5294660 (p.207) 20 education, we begin to hear of scurvy from various sources. Olaus Magnus16, in his “History of the Northern Nations,” published in 1555 , described the disease which he tells us flourished among the soldiers in the camps and in the prisons. About this time Ronsseus17, Echtius18 and Wierus19 wrote special treatises on this disease, and recommended many dietary measures which we recognize to-day as most efficacious. The number of monographs on this subject multiplied with great rapidity in the course of the next twenty-five or fifty years; none of them, however, added anything essential to our knowledge… This period [1700s] is distinguished rather by the appearance of a great classic on Scurvy, the work of the English naval hygienist, Lind (1752). This book has intrinsic value to-day, and, at the time it appeared, served to crystallize the conception of scurvy, which had been stretched out of all proportions to include an ever-increasing conglomeration of clinical conditions. Scurvy had become the Alpha and Omega of professional routine, the catchword of the day, the asylum ignorantiæ of the practical man. Into this chaos, as Hirsch20 expresses it, “the first beams of light fell when Lind’s classical work appeared.” 16 Olaus Magnus (1555) Historia de gentibus septentrionalibus. https://en.wikipedia.org/wiki/A_Description_of_the_Northern_Peoples https://doi.org/10.4324/9781315090399 [Vol II, English translation 1999] https://doi.org/10.4324/9781315090382 [Vol. III, English translation 1998] https://www.nb.no/items/URN:NBN:no-nb_digibok_2018120328001 [English translation 1658] https://books.google.fi/books?id=o9b5aGZH2noC https://runeberg.org/olmagnus https://runeberg.org/olmagnus/0401.html [in Latin, Scurvy on p.315-6; Book 9, Ch 38] https://runeberg.org/olmagnus/0656.html [in Latin, Scurvy on p.570-1; Book 16, Ch 51 Related documents: https://en.wikipedia.org/wiki/Olaus_Magnus https://doi.org/10.4000/belgeo.7677 17 Ronsseus, see: Lind. PART III: CHAPTER II, year 1564. 18 Echtius, see: Lind. PART III: CHAPTER II, year 1541. 19 Wierus, see: Lind. PART III: CHAPTER II, year 1567. Related: https://en.wikipedia.org/wiki/Johann_Weyer Lorentz AJ. Some Pre-Lind Writers on Scurvy. Proc Nutr Soc. 1953;12(3):306-24. https://doi.org/10.1079/PNS19530062 20 Hirsch, A.: Handbook of Geographical and Historical Pathology, see links above. 21 p.10-11 Infantile Scurvy.—Glisson21, to whom we owe the first description of rickets, likewise was the first to recognize scurvy in infants. In his classic treatise on rickets, written in 1668, he writes as follows: The scurvy complicated with this affect hath these signs: 1. They that labor under this affect do impatiently indure purgations; but they who are only affected with the Rachites do easily tolerate the same. 2. They are much offended with violent exercises, neither can they at all endure them. But although in this affect alone, there be a kind of slothfulness and aversation from exercise, yet exercise doth not so manifestly, at least not altogether so manifestly hurt them, as when the scurvy is conjoyned with the Rachites. 3. Upon any concitated and vehement motion they draw not breath without much difficulty, they are vexed with diverse pains running through their joynts, and these they give warning of by theyr crying, the motion of the Pulse is frequent and unequal, and somethimes they are troubled with a Palpitation of the Heart, or threatened with a Lypothymie, which Affects are for the most part soon mitigated, or altogether appeased by laying them down to rest… Glisson’s description of scurvy was entirely lost sight of, overshadowed by his description of rickets, so that for over two hundred years no word of infantile scurvy is to be found either in the English or other literature. There is no doubt that from time to time cases must have occurred, but they were looked upon probably as rickets or as a manifestation of one of the hemorrhagic diseases. 21 Glisson: Treatise on the Rickets, London, 1651. [Scurvy on p.249-250] https://doi.org/10.5281/zenodo.10206723 [Scurvy separately] https://archive.org/details/b30335693/page/248/mode/2up https://archive.org/details/b30327246/page/248/mode/2up https://archive.org/details/b30329589/page/248/mode/2up https://archive.org/details/bim_early-english-books-1641-1700_a-treatise-of-the-ricke_glisson-francis_1668/page/n251/mode/2up https://wellcomecollection.org/works/qn24bpgf/items?canvas=265 https://quod.lib.umich.edu/e/eebo/A86032.0001.001 See also: https://en.wikipedia.org/wiki/Francis_Glisson https://doi.org/10.1136/fn.78.2.F154 22 p.12 In 1883, Barlow22 23 published his classical paper on this subject, the first to furnish anatomical proof that this disorder of infants presented the pathological changes characteristic of adult scurvy. Previous to this publication there had been but one autopsy report, that by Moeller, which had been incorrectly interpreted. The work of Barlow was accepted remarkably quickly in England and in America, but less promptly on the Continent. This was probably due to the fact that infantile scurvy was occurring far more frequently in these two countries, and that the subject was open therefore to more prompt investigation. p.21 That scurvy must have occurred extensively among the infants in Vienna may be gathered from the report of Erdheim24, who records 31 autopsies on infants under the interesting title of the “Barlow Heart.” 22 Barlow, T.: (1) On Cases described as Acute Rickets, Med. Chir. Trans., 1883, LXVI, 159. https://doi.org/10.1177/095952878306600112 (1883) https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2121454 (1883) https://doi.org/10.1136/adc.10.58.223 (reprint in 1935) https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1975441 (reprint in 1935) https://en.wikipedia.org/wiki/Barlow%27s_disease 23 Barlow, T.: (2) Infantile Scurvy and Its Relation to Rickets, Lancet, London, 1894, II, 1075. https://doi.org/10.1016/S0140-6736(01)93995-9 The Bradshaw lecture in Lancet https://doi.org/10.1136/bmj.2.1767.1029 The Bradshaw lecture in BMJ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2405492 The Bradshaw lecture in BMJ https://www.jstor.org/stable/20230441 https://archive.org/details/b24905847 https://wellcomecollection.org/works/um6f7sfm The Bradshaw lecture original Biographies: https://doi.org/10.1136/bmj.287.6408.1862 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2056559 https://doi.org/10.1136/adc.20.102.49 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1987940 https://doi.org/10.1136/bmj.287.6408.1862 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1550031 https://doi.org/10.1017/s002572730005849x https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1036751 https://doi.org/10.1016/s0022-3476(57)80317-5 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1561482 https://en.wikipedia.org/wiki/Sir_Thomas_Barlow,_1st_Baronet 24 Erdheim J. The heart in infantile scurvy [Ueber das Barlowherz; in German, translation available]. Wien Klin Wochenschr. 1918;31(49):1293-5. https://doi.org/10.5281/zenodo.7756493 [English] 23 CHAPTER IV: PATHOLOGY p.81-83 Physicians have had a general knowledge of the pathology of scurvy for a great many years. Lind25, in his “Treatise on the Scurvy,” published in 1772, included a chapter on “dissections” and a postscript on “Appearances on Dissections of Scorbutic Bodies,” based on a large, although indefinite, number of postmortem examinations… Tissues were being carefully studied by means of the microscope, and scurvy was subjected to this new method of investigation. As a result of intensive application of this technic, a lesion of the bones was identified and established as characteristic of scurvy. Study was focussed so exclusively on the bones, that for many years, indeed until very recently, the other organs of the body were neglected. This is true of the gross as well as of the microscopic anatomy. Protocol after protocol gives a hasty account of the appearance of the various organs, merely as a routine introduction to a careful and often minute study of the bones (Table 2). As the result of this myopic vision, enlargement of the heart, for example, which should have been noted many years ago, was, until recently, unobserved—indeed, the heart is but occasionally mentioned in the protocols. p.83-84 Gross Pathology.—General Appearance.—The skin usually is pale, livid, and dotted with numerous petechiæ. These vary in size from the tiniest pin-points, barely recognizable to the naked eye, to ecchymoses of moderately large size. The most frequent site is the lower extremities... Generally there is some œdema about the ankles, and in children a somewhat characteristic puffiness about the eyes. General anasarca also occurs, in some cases associated with renal involvement. Peculiar boggy, “tumor-like” masses of localized edema may be present, which were considered by the earlier writers (Lind) to be one of the typical lesions of this condition. Hemorrhages.—Hemorrhage is such a striking manifestation that it is not surprising to find it was regarded by the older writers as the pathognomonic sign of scurvy. The bleeding may take place into almost any organ, and vary from small petechiæ to very extensive extravasations… p.85 The blood surrounds the muscle fibres, which appear quite intact. The neighboring blood-vessels are congested and may contain thrombi, both venous and arterial. Such thrombi are found also in areas where extravasation has not taken place, and conversely, hemorrhages occur where no thrombi are demonstrable, so that a mutual causal relationship cannot be proved. Further evidence in regard to the mechanism of these extravasations is presented in the discussion of the minute anatomy. Brownish pigment, undoubtedly derived from the blood, is frequently found in the neighborhood of the hemorrhagic areas. New connective tissue also grows in these areas, so that in healing cases a marked formation of scar tissue will be found. 25 Lind. Part II: CHAPTER VII Dissections. https://archive.org/details/b30511902/page/238/mode/2up 24 p.86-87 Anasarca.—This comprises the second characteristic lesion found in scurvy at necropsy and was referred to in the earliest records of the disease. In the account of his dissections Lind26 writes: “The breast, belly and several other parts of the body were filled with this water or serum,” mentioning also the pericardium and ventricles of the brain. He also noted that all the tissues seemed to contain an excessive amount of fluid, a condition which may be so striking that the muscles appear bathed in serum. In one of his first cases with postmortem verification, Barlow described this appearance as follows: “The muscular walls of the thorax were pale yellow and watery, as though they had been bathed in serum.” In many cases this edema is most marked in the neighborhood of the hemorrhages, for example, in the muscles of the thigh when subperiosteal hemorrhage has taken place; less frequently it is produced by venous thrombosis. Any or all of the serous cavities may be involved in this hydrops, the order of frequency being pericardium, pleuræ, peritoneum, and joint surfaces, especially the knee. The fluid is clear and straw-colored, or, in the event of secondary infection, becomes cloudy and fibrino-purulent. Later the exudate may become organized so that the entire cavity is filled with a solid mass, which binds the organs together and obliterates the cavity. The exudate may be blood-stained or apparently consist entirely of clotted blood. p.87-89 Heart.—In the protocols of most necropsies, the heart is passed over with scant mention. For example, Lind’s only statement in this regard is that “all those who died suddenly, without any visible cause of their death, had the auricles of their heart as big as one’s fist, and full of coagulated blood.” Barlow accords it no attention, nor do most of the writers who immediately followed him. The first careful description of the heart is to be found in the excellent work of Schoedel and Nauwerk27, which contains the following record in regard to three of the five necropsies on infantile scurvy: (1) Pericardial fluid somewhat increased, both ventricles moderately dilated, the right somewhat hypertrophic. (2) The heart showed a hypertrophy of the right and left ventricles, as well as dilatation of the right ventricle. (3) The right ventricle is dilated and slightly hypertrophied, the muscles pale and tough. There is no word of comment relative to these cardiac changes, which evidently were considered fortuitous. The same observation holds true in regard to a necropsy on an eight-year-old child reported by Ingier28 29, which showed a moderate hypertrophy of the left ventricle. We look in vain, likewise, for information on the subject in the work on guinea-pig scurvy 26 Lind. Part II: CHAPTER VII Dissections, cases N° 4, 6, 20. https://archive.org/details/b30511902/page/238/mode/2up 27 Schoedel, J., and Nauwerk, C.: Untersuchungen ueber die Moeller-Barlow’sche, Krankheit, Jena, 1900. https://archive.org/details/39002011126951.med.yale.edu/page/n3/mode/2up https://archive.org/details/untersuchungenb10unkngoog/page/n4/mode/2up 28 Ingier, A.: (1) Beitraege zur Kenntnis der Barlowschen Krankheit, Frankfurt. Ztschr. f. Path., 1913, XIV, 1. 29 Ingier, A.: (2) A Study of Barlow’s Disease Experimentally Produced in Fetal and Newborn Guinea-pigs, Jour. Exper. Med., 1915, XXI, 525. https://doi.org/10.1084/jem.21.6.525 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2125288 25 CHAPTER VII: SYMPTOMATOLOGY AND DIAGNOSIS p.176-180 Adult Scurvy.—The earliest sign of scurvy is usually a change in the complexion of the individual. His color becomes sallow or muddy, an aspect difficult to describe, but one which is characteristic, and constitutes an important danger signal to the eye of the experienced physician. About the same time the patient loses his accustomed vigor, seemingly becomes indolent and complains of tiring quickly, and of breathlessness. He may experience fleeting pains in the joints and limbs, especially in the legs, symptoms which are frequently attributed to rheumatism. At this early stage the appetite may still be normal, there is usually no loss in weight, but merely a general malaise which is significant, although in no way distinctive. Very soon the gums become sore, bleed readily, and are found to be congested, spongy, and somewhat hemorrhagic at their edges. Absolute reliance must not, however, be placed on this sign for early diagnosis, as at times it does not appear until later. Careful examination at this stage will disclose petechial spots on the body, more especially on the legs, at the site of the hair follicles, or even larger ecchymoses, depending upon the hemorrhagic tendency of the individual, his exposure to bruising, the adequacy of his diet, and secondary infection. Less frequently bleeding from the nose occurs early, or the eyelid suddenly becomes swollen and purple, or the urine shows the presence of blood. These signs progress steadily with a varying degree of rapidity. The complexion becomes more dingy and somewhat brownish, the weakness increases so that the slightest exertion causes breathlessness and palpitation, and the gums become spongy and even fungous. If there is infection of the gums and the teeth are carious, the breath is extremely foul—a sign long associated with scurvy. Later the teeth become loose and may fall out, and the alveolar process undergoes necrosis. The surface hemorrhages increase in severity, large effusions appearing on the trunk, on the extremities, and less often beneath the mucous membrane of the mouth. A bloody diarrhœa may take the place of the constipation which is generally noted earlier in the disease. There are at this time hemorrhages into the muscles and deeper tissues, especially into the calves of the legs, giving rise to hard, brawny, tender swellings which have been termed “scurvy sclerosis.” This is sometimes the earliest sign noted by the patient and may puzzle the physician who has not met with it before. The swelling may be found in the popliteal space or at the site of the tendo Achilles, and result in lameness and contracture of the neighboring joint. Frequently there is slight edema of the ankles associated with a glossiness of the extensor surfaces of the legs. This infiltration differs from ordinary edema in being firm and not pitting on pressure. The skin is dry and rough, the follicles being unusually elevated; the hair likewise is dry and loses its lustre. Not infrequently subperiosteal hemorrhages occur, giving rise to exquisitely tender swellings, especially of the tibia or of the femur, or of the ramus of the lower jaw, as has been noted in connection with guinea-pig scurvy. If there are wounds or ulcers they assume a hemorrhagic aspect, the edges becoming bluish or livid and showing no tendency to heal; even scars which have existed for many years change in color and show an altered state of nutrition, and ulcers long healed break out afresh. Nowadays, the disease usually does not reach this stage, and rarely progresses further. If, however, the patient remains untreated, he becomes progressively weaker and more lethargic; there is frequent palpitation, shortness of breath, and increasing loss of weight. The pains in the limbs render him helpless and an object of pity. Marked edema may be added to the picture as the result of starvation, so that the legs become swollen, and even the face becomes bloated. Hemorrhages into the skin as large as the palm of the hand appear on different parts of the body. The gums swell to such an extent that they overlap and may even hide the teeth and protrude from the mouth as foul 32 fungoid growth. Death comes about in various ways. Frequently sudden and fatal syncope occurs, due to heart weakness or to the pouring out of fluid into the pleural or the pericardial cavities. Another frequent cause of death is secondary infection, resulting in pneumonia, which finally ends the suffering of the patient. The fatal outcome is thus described in the narrative of Lord Anson’s voyage46: Many of our people, though confined to their hammocks, ate and drank heartily, were cheerful, and talked with much seeming vigor, and in a loud, strong tone of voice; and yet, on their being the least moved, though it was only from one part of the ship to another, and that in their hammocks, they have immediately expired; and others, who have confided in their seeming strength, and have resolved to get out of their hammocks, have died before they could well reach the deck. And it was no uncommon thing for those who could do some kind of duty, and walk the deck, to drop down dead in an instant, on any endeavor to act with their utmost vigor; many of our people having perished in this manner during the course of this voyage. The disease may develop and progress in various ways. It may remain latent for a long period and be cured by some accidental change of diet, or, as more frequently occurs, it runs a moderately acute course, and is promptly cured by means of antiscorbutics. In the days when scurvy was common and widespread it sometimes became chronic, developing into the “inveterate scurvy” of the older authors, which was notably resistant to treatment. Harvey47, in his treatise published in 1685, states that “a mild scurvy may continue or be protracted to ten, twenty, or thirty years.” p. 181-182 The pulse is sometimes slow and feeble, having been recorded as low as 40 beats per minute, but more frequently is rapid, in the neighborhood of 140. It is, however, almost invariably unduly excited by emotion or by mild physical activity. Frequently there is a low type of fever, which has been termed “scorbutic fever,” but which probably should be regarded as a complication of the disease rather than as an intrinsic symptom. The urine is apt to be scanty, becoming much more profuse following treatment. Perspiration is also retarded. Pericarditis, hydrothorax, pleurisy with effusion, pneumonia, are common complications of severe forms of scurvy. Lind reports that the dominant complication varies in different epidemics; that on one cruise many cases of diarrhœa would occur and on another many pulmonary infections. 46 Anson, Lord: Walter and Robins, Voyage Round the World, London, 1848. See Lind. PART III: CHAPTER II, year 1748. Links available. 47 Harvey, G.: A New Discourse of the Smallpox and Malignant Fevers with an Exact Discovery of the Scurvy, London, 1685. https://name.umdl.umich.edu/A43016.0001.001 https://wellcomecollection.org/works/ee8fvrhh 33 p.183-187 Infantile Scurvy.—The stereotyped picture of infantile scurvy and the one which this term commonly suggests, is that of the acute form of the disease. In acute infantile scurvy we have to do generally with a poorly-nourished, pale infant with a peculiarly alert and worried expression. As we approach its bed it whimpers or cries out in terror. Frequently its posture is characteristic, as it lies quietly on its back with one thigh everted and flexed on the abdomen. Examination shows that one or even both thighs are swollen and exquisitely tender, or that there is merely tenderness, the baby shrieking at the slightest pressure upon the lower end of the femur. If teeth are present, the adjacent gums are red, swollen and bleed readily. This is the syndrome which the medical student is taught to carry away to guide him in his everyday practice. It is the acute, florid type, and presents a striking picture, but must not be regarded as the common form of the disorder. If we are to diagnose infantile scurvy early and not overlook its more subtle manifestations, the classic textbook description must be augmented by portrayals of types of the disorder which are less crude and more difficult to recognize—of “subacute” and of “latent” scurvy. The commoner form, which we have termed “subacute infantile scurvy,” comprises a large number of symptoms which are inconclusive individually, and frequently escape correct interpretation. The affected baby is usually in the second half of the first year of life, and does not gain in weight or gains but slightly for weeks. It may be fairly well nourished, but is pale or sallow, with perhaps slight edema of the upper eyelids. The mother or nurse complains that the child is irritable and peevish, and that the appetite is poor or capricious. The gums show a lividity or slight peridental hemorrhage, which on subsequent examination may be no longer visible, and may have consisted merely of a rim of crimson edging the borders of the upper gum, perhaps behind an upper incisor, as Still pointed out. On closer examination it may be observed that the papillæ of the tip of the tongue are markedly congested, and that a petechial spot is to be seen on its frenum, on the palpebral conjunctiva, or here and there on the surface of the body, more especially where there are erosions, eczema or other skin lesions. Attention may be called to tenderness of the lower thighs, which in some instances is definite, in others so ill-defined and fleeting that it is impossible to convince oneself of its significance or even reality. There may be slight edema over the crests of the tibia, of a kind which does not pit on pressure. The knee-jerks are almost always markedly exaggerated. The urine is diminished in volume but is generally normal or contains a trace of albumen and red and white blood-cells. The pulse is frequently rapid, and becomes markedly rapid and irregular on the slightest excitement. The respirations are also rapid (Fig. 15). These symptoms do not constitute a rigid entity, but are subject to manifold variations… An instance of subacute scurvy, which in many respects is typical, is the following: I. F., girl, was seen when 3 months old… Accompanying this lack of gain in weight there were many of the other symptoms enumerated above; irritability, pallor, slight tenderness of the lower ends of the femora, albumin and a few red and white cells in the urine. The pulseor heart-beat was frequently over 150, and the respiration 60 (Fig. 15). The diagnosis of subacute scurvy was substantiated by the prompt subsidence of all symptoms when orange juice was administered. Infantile scurvy may be dormant for a long time. The diagnosis of latent scurvy is based mainly on the reaction to specific therapy, on the marked improvement when orange juice, tomato, potato or 34 other antiscorbutic food is given. The symptoms themselves are suggestive, and do not enable an absolute diagnosis to be made. … the history of a diet of heated milk, especially if the quantity was not large, considered in conjunction with the pallor and poor appetite, the increased knee-jerks, and perhaps a rapid pulse and respiration (the cardiorespiratory syndrome), has awakened suspicion. Orange juice or canned tomato, prescribed in such cases with a view to diagnosis as well as to treatment, frequently brings about a magic result. p.188-189 When scurvy goes unrecognized or untreated for a long time, or the antiscorbutic content of the food is exceptionally small, or the patient unusually susceptible, the disorder may progress and resemble the advanced cases described in connection with the adult type of this disease. Happily such instances are rare. One of the most typical and vivid descriptions of an extreme case of infantile scurvy is that reported by Vincent48: The infant lay in its bed extremely apathetic and barely conscious. Its face was ashy gray in color, the respirations were extremely frequent, the pulse-rate was 144 per minute, and the temperature 103.2°. When touched it moaned feebly, and made no attempt at movement. The mouth was kept open, the lower jaw hanging away from the face. There was a complete absence of muscular tone, so that the infant appeared to be quite incapable of voluntary movement. … The baby was given large amounts of lemon juice and subcutaneous injections of salt solution and the necrosing surfaces of the gums were scraped and swabbed with boracic solution. By the third day the pulse was 100, the temperature 99.8°, the odor from the mouth scarcely noticeable, and the general condition distinctly improved. It continued to improve and to gain in weight and when seen at the end of the sixth week of treatment it was doing well and was quite happy. p.193-194 As mentioned above, hemorrhages into the muscles or between the muscle planes are very common in adults, leading to hard swellings, the typical “scurvy sclerosis.” Such effusions occur much less frequently in infants, due probably to their lack of activity. In addition to these hemorrhages there are serous effusions of the muscles similar to those which are found in the pleural and pericardial cavities. These effusions are very striking at necropsy, when one incises the muscles—for example, the muscles of the thigh. During life they are frequently mistaken for subperiosteal hemorrhages. Less frequently there are hemorrhages into the internal organs. These, however, play a comparatively insignificant rôle in the symptomatology of this disease. At postmortem examination we find numerous hemorrhages of the pleura, pericardium and peritoneum, which rarely produce symptoms during life… Hæmothorax and hæmopericardium occur… 48 Vincent, R.: The Nutrition of the Infant, New York, 1904, Wm. Wood & Co. https://archive.org/details/nutritioninfant00vincgoog/page/n276 [Scurvy p.254-65; the case on p.262-4]. 35 p.195-197 … A case of this kind is the following: M. L., seven months old, was getting “Molkenadaptierte” milk, and in addition autolyzed yeast. On May 25th it developed nasal diphtheria, but soon afterward did well. On June 9th it was gaining, but its pulse was 160 and respirations 80. A few days later it developed marked eczema about the neck and to a less extent on the back and buttocks. The “capillary resistance test” was negative. Cardiographic tracings showed merely a simple tachycardia. A few days later petechial spots appeared at the site of the eczema. On June 17th orange juice was given. The appetite improved, the cardiorespiratory syndrome disappeared, and the child began to gain. The eczema also cleared up rapidly without any local treatment. As is well known, edema constitutes a not infrequent symptom of adult scurvy. It has not, however, been accorded any place in the symptomatology of infantile scurvy. We do not refer to the edema in connection with subperiosteal hemorrhage or separation of the epiphyses of the long bones, but a mild and peculiar form which is seen early in the disease. It involves most regularly the upper eyelids, and the legs—especially the skin covering the lower part of the tibiæ. In the latter site it differs from edema as usually encountered, in that it does not pit on pressure; it is firm, tense, causing some glossiness of the overlying skin, which is rendered difficult to wrinkle or to pinch between the fingers. Not infrequently the skin is slightly reddened, a sign of interest, in view of a similar, although much more intense, hyperæmia seen in pellagra. In addition to this very mild edema there may be marked swelling, resulting in what might be called, following the terminology of beriberi, “wet scurvy.” The legs, body and even the face may be swollen. This has been frequently described in adult scurvy, and occasionally in infantile scurvy. The first case of infantile scurvy described in America, that of Northrup49, had marked edema of the scrotum. Edema is frequently met with in “ship beriberi,” a disorder considered by some writers to be a combination of beriberi and scurvy. The symptom leading to the diagnosis of scurvy most often is tenderness or swelling of one of the extremities, as the antecedent clinical signs, comprising latent scurvy, are generally overlooked. These manifestations involve usually the distal end of the thigh or thighs… p.199-202 The cardiovascular system has been given but scant attention in connection with scurvy. Adults complain not infrequently of palpitation and pain over the pericardium, or rather of a tightness or oppression in the chest. Little information is given regarding the size of the heart. Darling described enlargement of the heart, especially a right-sided hypertrophy, which he thought was pathognomonic of the Rand type of scurvy. The pulse is described in some cases as slow, and in others as rapid. In descriptions of infantile scurvy the entire subject is generally passed over without 49 Northrup, W. P.: Scorbutus in Infants, Arch. of Pediat., 1892, IX, 1. https://babel.hathitrust.org/cgi/pt?id=uva.3470143072&seq=13 Related publications: New York medical journal for May 26, 1894 https://archive.org/details/101747078.nlm.nih.gov https://resource.nlm.nih.gov/101747078 https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101747078-bk 36 mention—for example, in the excellent report of the American Pediatric Society50 nothing whatsoever is stated regarding the heart’s action or the pulse. Barlow wrote: “There is nothing to note regarding the heart and lungs.” In a paper written a few years ago, it was pointed out by the author that there is frequently enlargement of the heart, and more especially of the right heart. This can be elicited at the bedside and has been substantiated in numerous cases by means of the Röntgen-ray, which demonstrates not only enlargement of the heart, but also a marked broadening at its base, at the site of the large vessels. These phenomena resemble closely the description of Reinhard in cases of beriberi. Necropsy protocols usually are incomplete and unsatisfactory in their descriptions of the heart. The excellent monograph of Schoedel and Nauwerk, however, which reports five careful necropsies, contains the following data regarding three: 1. Pericardial fluid somewhat increased, both ventricles moderately dilated, the right somewhat hypertrophic. 2. The heart showed a hypertrophy of the right and left ventricles, as well as dilatation of the right ventricle. 3. The right ventricle dilated and slightly hypertrophied, the muscles pale and tough. In addition to this enlargement of the heart, or perhaps associated with it, there is a combination of signs which has been termed “the cardiorespiratory syndrome” (Hess).51 It will be noted in the above description of a case of subacute scurvy, that the pulseor heart-beat was frequently over 150, and the respiration 60. These phenomena were noted in several instances before their significance and intimate relationship to scurvy were realized. The heart-beat not infrequently is found to be 200 per minute, and to be characterized by marked lability—increasing to an astonishing degree as the result of slight exertion or excitement. A mild febrile disturbance causing a rise of temperature to little more than 100° F. will send the pulse-rate up 30 beats. It must not be thought that this refers to severe cases; the babies we have in mind are similar to the one cited as an instance of subacute scurvy. Apparently they are not ill, but show merely some tenderness of the thighs, pallor, and the other minor signs described. The cardiographic tracings showed a simple tachycardia with an exceptionally tall T-wave in some tracings, such as is commonly seen in exophthalmic goitre (Fig. 22). The rapidity of respirations is perhaps a more delicate indicator of this disturbance than the pulse and has been found to be markedly affected when the latter was merely slightly increased in rate. For example, in one instance the respirations were 64, 60 and 64 on three successive days, while 50 American Pediatric Society: Collective Investigation on Infantile Scurvy in North America, Arch. of Ped., 1898, XV, 481. Related publications: https://doi.org/10.1056/NEJM189806301382601 https://doi.org/10.1056/NEJM189807071390102 https://doi.org/10.1136/bmj.2.1967.750 51 Hess, A. F.: (4) Subacute and Latent Infantile Scurvy, The Cardiorespiratory Syndrome (a New Sign), Jour. Am. Med. Assn., 1917, LXVIII, 235. https://doi.org/10.1001/jama.1917.04270010235001 https://doi.org/10.5281/zenodo.10102042 37 the pulse was 124, 141 and 136; in other words, there was a 2:1 instead of the normal 4:1 pulserespiration ratio. The accompanying chart illustrates the phenomenon in all its details better than a verbal description. There is one point in connection with it, to which especial attention should be called. This is a reaction evident at a glance at the chart—the sharp drop in the pulse and in the respiratory rate when orange juice was given. It is the essence of the phenomenon; a therapeutic response which proves that the rapidity is scorbutic in nature. The main involvement of the respiratory system in scurvy is the polypnœa just described in connection with the cardiorespiratory syndrome. There is no aphonia, a sign so typical of adult and of infantile beriberi, although at times the voice is abnormal and whining. The lungs frequently show some dullness posteriorly, which may be due to engorgement or to the pressure of the enlarged heart. Pneumonia is a frequent complication and edema a terminal event. Hydrothorax associated with hydropericardium is of frequent occurrence, and was noted in the early description of this disease in adults and in the first account of Barlow. These effusions rarely progress to what may be termed the clinical degree and under antiscorbutic treatment are rapidly absorbed. It is commonly thought that scurvy does not involve the nervous system; that this is a feature which distinguishes it sharply from beriberi, another “deficiency disease.” This view is incorrect, for the nervous system is probably affected in many cases of scurvy. The rapidity and lability of the pulse, combined with the rapid respirations, would seem to be due to a disturbance of the vagus mechanism… p.203-206 In view of many of these symptoms, especially those involving the vagus, scurvy must be looked upon as a disorder which may seriously affect the nervous system. Furthermore, when we note the marked reaction brought about by the antiscorbutic vitamine—for example, the sharp fall in the rate of respirations and of pulse, as shown in Fig. 15, after giving orange juice, we must conclude that the antiscorbutic vitamine functions, at least indirectly as an antineuritic vitamine—that it must possess this character to allay the various nervous signs of this disorder. The urinary system is frequently involved in the course of scurvy… Oliguria is a common symptom of both adult and infantile scurvy. Lind mentioned this symptom, and in this connection remarks on the beneficent effect of antiscorbutic treatment. Charpentier52 called attention to the fact that in a case of scurvy the urine decreased from 1250 g. to 800 g. The report of the American Pediatric Society mentions scanty urine in 9 cases and suppression of urine in one. This sign, however, was not emphasized until recently, when Gerstenberger53, and Hess and Unger drew attention to its frequent occurrence in infants. It has some diagnostic significance and should be borne in mind where a decreased excretion of urine is reported. A counterpart of this symptom is the sudden outpouring of urine frequently noted after antiscorbutic treatment has been instituted. This polyuria accounts for the loss of weight or lack of gain which sometimes accompanies unmistakable general improvement, and which is difficult otherwise to understand (Fig. 23). 52 Charpentier, P.: Étude sur le Scorbut, Paris, 1871, A. Delahaye. https://archive.org/details/b22344287 53 Gerstenberger, H. J.: Pathogenesis of Infantile Scurvy, an Hypothesis, Am. Jour. Med. Sci., 1918, CLV, 253. https://archive.org/details/paper-doi-10_1097_00000441-191802000-00008 38 p.209 Scurvy is associated with an alteration of both the blood and the blood-vessels. The characteristic pallor, which is one of the most common as well as earliest symptoms, is due in a large measure to the anemia… p.212-213 The investigation was directed to a study of the integrity of the blood-vessels in order to account for the hemorrhages. To this end the “capillary resistance test” was devised. In the majority of cases this was found to be “positive” (the blood-vessels showing an increased permeability) and to become negative when antiscorbutics were given and the symptoms disappeared. This shows that the cellular structure of the vessels is altered in the course of scurvy, and indicates probably that this is an important cause of the hemorrhages. The edema of the face and ankles, the outflow of serum into the body cavities and into the muscles (Barlow) must be regarded as other evidences of the inadequacy of the vessel walls. The tendency of children with exudative diathesis to develop scurvy is perhaps still another manifestation of vascular weakness. This point of view has been strengthened recently by the pathological studies of Aschoff and Koch, who regard scurvy as a nutritional disorder in which there is a lack of some colloidal substance needed for the normal structure of the vessels. p.216 Fever.—Fever frequently accompanies scurvy. It is generally of a low grade, ranging between 100° and 101°, as may be seen in Fig. 15. There is a difference of opinion as to whether the rise of temperature should be considered as truly scorbutic in nature, as “scorbutic fever,” or regarded merely as a condition grafted upon the nutritional disturbance. A phenomenon which might seem to argue for its essential scorbutic character is the sharp subsidence on giving antiscorbutic food… DIAGNOSIS p.219 It has been our experience that medical students who were conversant with scurvy from a theoretical standpoint failed to diagnose a case presented to them in the clinic. Where diagnosis is uncertain, the most important aid is an exact knowledge of the previous diet, and observation of the reaction of the patient to antiscorbutic treatment. p.221-222 We have thus far had in mind frank and outspoken cases of scurvy. When we come to consider latent or early cases, the diagnosis is more difficult and may have to be merely tentative. All that need be added, in view of the clinical picture sketched above, is that this condition should not be forgotten in treating adults who have malaise and indefinite “rheumatic” pains and, more particularly, in relation to infants who fail to gain, whose appetite is capricious, whose disposition has become fretful and who have developed the sallow scorbutic complexion. 39 p.224 The most important consideration in the diagnosis of scurvy is to keep in mind the heterogeneous character of its symptoms, and the manifold diseases with which it may be confused. Surgeons should be alert to this danger when about to perform operations for osteomyelitis or bone tumor. The mistakes occur because cases are infrequently seen and because the signs, being dependent largely upon hemorrhage, occur in such varied locations of the body. Where diagnosis cannot be made from the signs or symptoms, the most important aid is a thorough acquaintance with the previous diet of the individual and observation of his reaction to antiscorbutic treatment. CHAPTER VIII: PROGNOSIS p.227 In adults the heart may be weakened by scurvy, and death may result from cardiac failure. Cardiac disturbances occur also in infantile scurvy. This involvement might be expected, in view of the tachycardia (cardiorespiratory phenomenon) which is so frequent a symptom of infantile scurvy. The heart may be rapid for months or even for years after the disorder, and tachycardia may develop on the occasion of even a mild infectious disease. For example, a fever of 101°, due to a common coryza, may cause the heart-beat to rise to perhaps 180 a minute. Children so affected succumb readily to infection, especially to pneumonia, which may lead to sudden collapse followed by death. CHAPTER IX: TREATMENT p.236-237 Cure.—There is almost nothing in the realm of therapy which is so striking as a scorbutic patient’s prompt reaction to antiscorbutic treatment. It is all the more marvelous as the cure is effected by means of foodstuffs with which we are accustomed to associate no specific virtue. A magic result is seen frequently within 24 or 48 hours. A baby which has had a poor appetite, has been irritable and exquisitely tender, suddenly regains its appetite, is no longer fretful, and can be handled without occasioning crying. Within a week, if the case is mild, all definite symptoms of scurvy may have disappeared, and soon thereafter the infant is thriving and apparently cured… In most instances a gain of weight accompanies improvement. In not a few instances, however, there is a temporary loss or cessation of weight, due in part to an increased excretion of urine… p.239-240 Non-dietetic Therapy.—There is little to be done for the patient in addition to the giving of sufficient antiscorbutic. No one has reported success with any drug… The patient should be kept in bed, and exertion not allowed on account of the involvement of the heart, which has led to sudden collapse and death. 40 CHAPTER XI. RELATION OF SCURVY TO OTHER DISEASES p.249-250 Although at first thought beriberi and scurvy would seem far apart from a clinical point of view, they have some important features in common. In both there is a tendency to a rapidity of the heart’s action and a marked lability of the pulse, to an enlargement of the cardiac ventricles, to an involvement of the vagus, and to an exaggeration of the deep reflexes. It is unnecessary to describe these signs and symptoms in detail, as they have been fully considered under symptomatology. It has been recorded from time to time that under certain circumstances scurvy has developed in man where one should have expected beriberi, and vice versa. Darling, who has had a large experience in this field, writes: “A deficient dietary in a tropical African negro mine laborer causes severe scurvy, in a Cape Colony African mine laborer, mild scurvy, and in some African negroes a diet that causes scurvy in one set of men causes neuritis in others.” Possibly some minor differences in the dietary can explain this difference in reaction—for we do not know all the sources of the water-soluble vitamine, but such an experience deserves to be cited as it is not an isolated instance. It is all the more worthy of attention because it harmonizes to a certain extent with the everyday experience of animal investigation. As has been stated elsewhere, a diet of decorticated grain will lead to scurvy in the guinea-pig, to polyneuritis in the pigeon, and to a combination of these diseases in the hog! Results of this kind show that there must be a relationship between the etiologic factors of scurvy and of beriberi. It is unwise at present to attempt to define the relationship more precisely. The remarkable observation, first made by Fuerst54, and since confirmed by numerous investigators, that seeds and legumes are devoid of antiscorbutic potency but acquire this power on sprouting, constitutes another link in the evidence of their kinship. Funk55 56 has suggested that the antiscorbutic vitamine can be formed from the “antineuritic” vitamine, a theory which is very attractive but needs confirmation and experimental proof. It is quite evident that this change does not usually occur in animals, in view of the specificity of the vitamines for their respective diseases —of the antiscorbutic for scurvy and the water-soluble for beriberi. 54 Fuerst, V.: Weitere Beitraege zur Aetiologie des experimentellen Skorbuts des Meerschweinchens, Ztschr. f. Hyg. u. Infektionskrankh. 1912, LXXII, 121. https://doi.org/10.1007/BF02216487 55 Funk, C.: (1) On the Chemical Nature of the Substance which Cures Polyneuritis in Birds, Jour. Physiol., 1911, XLIII, 395. https://doi.org/10.1113/jphysiol.1911.sp001481 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1512869 56 Funk, C.: (2) Die Vitamine, Wiesbaden, 1914, J. F. Bergman. https://digital.library.cornell.edu/catalog/chla3151057 [English] https://archive.org/details/dievitamineihre00funkgoog [German] Related documents: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1354134 https://doi.org/10.1159/000319165 https://www.researchgate.net/publication/46095638 https://www.jstor.org/stable/45202920 https://doi.org/10.1093/jn/102.9.1105 https://doi.org/10.3945/jn.112.171827 https://doi.org/10.1111/j.1753-4887.1962.tb04533.x https://doi.org/10.1024/0300-9831/a000124 https://en.wikipedia.org/wiki/Casimir_Funk 41 Lind J. A Treatise of the Scurvy in Three Parts (1753/1757/1772) A Treatise on the Scurvy, in Three Parts. Containing an Inquiry into the Nature, Causes, and Cure, of that Disease. Together with a Critical and Chronological View of what has been published on the Subject. Lind’s treatise on scurvy was published in three editions in1753 (1st ed), 1757 (2nd ed), 1772 (3rd ed). In 1953, as a bicentenary volume, the 1st edition was reprinted with modernized fonts by Edinburg at the University Press. Lind J. A Treatise of the Scurvy in Three Parts (1753/1757/1772) https://doi.org/10.1111/j.1753-4887.1983.tb07177.x (Nutrition Classic) https://doi.org/10.1017/CBO9781107256644 (1st ed. republication) https://archive.org/details/b30507054 (1st ed 1753) https://wellcomecollection.org/works/xc2t7736 (2nd ed 1757) https://archive.org/details/treatiseonscurvy00lind (2nd ed 1757) https://archive.org/details/treatiseonscurvy1772lind/page/n5/mode/2up (3rd ed 1772) https://archive.org/details/b30511902/page/n5/mode/2up (3rd ed 1772) https://archive.org/details/bim_eighteenth-century_a-treatise-on-the-scurvy_lind-james_1772 (3rd ed) https://babel.hathitrust.org/cgi/pt?id=ucm.5320216006 (3rd ed 1772) https://babel.hathitrust.org/cgi/pt?id=ucm.5320216015 (3rd ed 1772) https://archive.org/details/b28771308_0001 (French, 1783) https://archive.org/details/b28771308_0002 (French, 1783) https://archive.org/details/traitduscorbutdi00lind (French, 1783) https://archive.org/details/traitduscorbutdi00lind_0 (French, 1783) https://archive.org/details/TrattatoDelloScorbutoDivisoInTreParti (Italian, 1766) 48 Lind’s Treatise on Scurvy (1953) Reprint of the first edition, with modern fonts. Edinburgh University Press Reviews of the 1953 version https://doi.org/10.1113/expphysiol.1953.sp001028 https://doi.org/10.1001/jama.1953.03690150096035 https://doi.org/10.1056/NEJM195310012491410 Stewart CP, Guthrie, D (1953) Editor’s Foreword to the Bicentennary Volume. https://doi.org/10.5281/zenodo.10604636 Addional Notes in the Bicentennary Volume: Stewart CP (1953) Third Edition of the Treatise. https://doi.org/10.5281/zenodo.10604737 Dudley S (1953) The Lind Tradition in the Royal Naval Medical Service. https://doi.org/10.5281/zenodo.10605143 Guthrie D, Meiklejohn AP (1953) James Lind and Some of his Contemporaries. https://doi.org/10.5281/zenodo.10605213 49 Certain old terms in Lind’s text: Asthma: In the 1700s, the term “asthma” referred to various kinds of dyspnoea and related symptoms, which included non-pulmonary causes, e.g cardiac causes of breathlessness, “cardiac asthma”. The Greek term asthma, used by Homer for a gasping, painful breathing, had acquired a distinct medical sense by the time of Hippocrates. https://doi.org/10.1017/CHOL9780521332866.030 Derived from the Greek root, meaning “to pant heavily” or “gasp for breath”. https://doi.org/10.1164/rccm.200402-185oe Laborious respiration with lifting of the shoulders and wheezing. https://doi.org/10.1164/rccm.200502-257oe Heaviness of the chest… difficulty in breathing on a steep road… https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5379292 Dropsy: The historical diagnosis of dropsy – which is now obsolete – indicated simply an abnormal accumulation of fluid. The word derives from the Greek hydrops (water). Alternative or supplementary terms included hydrothorax (fluid in the chest cavity), ascites (which still indicates excess free fluid in the abdominal cavity), anasarca (still used to describe generalized edema throughout the body). https://doi.org/10.1017/CHOL9780521332866.101 An ancient medical term used to indicate different conditions including chronic heart failure. https://doi.org/10.1016/j.ijcard.2017.07.104 Some symptoms of edema in those called oidêma (swelling) and udrôps (dropsy) in the oldest treatises of the Corpus. https://doi.org/10.1159/000013442 Flux: Diarrhea, marked by the frequent production of watery stools, may be confused with dysentery in historical accounts, but references to “bloody flux” refer to true dysentery. https://doi.org/10.1017/CHOL9780521332866.102 Costiveness – constipation Countenance – the appearance of someone’s face Hypochondrion – in ancient texts, denoted the soft part of the body below the ribs. Orthopnoea – difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position Purge – to cause evacuation from (the bowels) Rind – skin, peel, outer layer 50 ADVERTISEMENT to the 3rd ed (1772) [not in the 1st edition] (p.iii-vi) This treatise now makes its appearance in a third edition, improved by the knowledge and experience acquired from an almost constant attendance for thirteen years, on patients afflicted with the scurvy. Though the disease has of late raged with great mortality in different parts of the world, as will appear from the Supplement, yet perhaps, no spot whatever has exhibited more numerous or more distressing cases of it than Haslar hospital57 : I here frequently visited, during five years of the late war with France (from the year 1758 to 1763), three or four hundred scorbutic patients in a day ; every morning furnished me with original pictures of the disease, in all its various forms and stages, in patients brought from all quarters of the globe : on comparing these with accounts of authors, I found the disease to be precisely the same in every age, and in every country. But the outward face of the disease did not alone engage my attention ; the dead were carefully inspected ; and every medicine, or method of cure, that could be suggested, was tried for the relief of the distressed. The result of these inquiries is now made public : in the Postscript, and a few other parts of this work, I have inserted the substance of four volumes of observations, daily and carefully made in the chambers of the sick. … What I have been more anxious about, than any theory, is to transmit to posterity a faithful register of all books and observations which have been published on this disease ; together with the most effectual means hitherto discovered to check its progress, lessen its violence, and prevent its devastation. I have, in the Postscript, put my last hand to a work, which in all probability I shall not further enlarge ; being perswaded I can carry my researches no further, without launching into a field of conjecture and uncertainty… 57 Haslar hospital. https://www.royalhaslar.com/history https://en.wikipedia.org/wiki/Royal_Hospital_Haslar https://www.jameslindlibrary.org/articles/the-royal-hospital-haslar-from-lind-to-the-21st-century 51 PREFACE p.5-7 (3rd p.vii-xiv) The subject of the following sheets is of great importance to this nation ; the most powerful in her fleets, and the most flourishing in her commerce, of any in the world. Armies have been supposed to lose more of their men by sickness, than by the sword. But this observation has been much more verified in our fleets and squadrons ; where the scurvy alone, during the last war, proved a more destructive enemy, and cut off more valuable lives, than the united efforts of the French and Spanish arms… It is now above 150 years since that great sea-officer, Sir Peter Hawkins58, in his observations made in a voyage to the South sea, remarked it to be the pestilence of that element. He was able, in the course of twenty years, in which he had been employed at sea, to give an account of 10,000 mariners destroyed by it… It was acknowledged, that the best descriptions of it are met with in the accounts of voyages : but it was regretted, that those were the productions only of seamen ; and that no physician conversant with this disease at sea, had undertaken to throw light upon the subject, and clear it from the obscurity under which it has lain in the works of physicians who practised only at land… But as it is no easy matter to root out old prejudices, or to overturn opinions which have acquired an establishment by time, custom, and great authorities ; it became therefore requisite for this purpose, to exhibit a full and impartial view of what has hitherto been published on the scurvy ; and that in a chronological order, by which the sources of those mistakes may be detected. Indeed, before this subject could be set in a clear and proper light, it was necessary to remove a great deal of rubbish. 58 Richard Hawkins (1622) Voyage into the South Sea, in the Year 1593. https://www.gutenberg.org/ebooks/57502 https://www.gutenberg.org/files/57502/57502-h/57502-h.htm https://doi.org/10.4324/9781315555058 https://www.routledge.com/The-Observations-of-Sir-Richard-Hawkins-Knt-in-his-Voyage-into-the-South/Bethune/p/book/9781409412670 https://archive.org/details/cihm_18326 https://archive.org/details/cihm_36497 https://archive.org/details/hawkinsvoyagesdu00markrich https://archive.org/details/observationsofsi00hawkrich https://archive.org/details/observationsofsi00hawk https://archive.org/details/observationsofsi00hawk_0 https://archive.org/details/dli.ministry.04871 https://archive.org/details/observationssir00bethgoog https://archive.org/details/observationssir01bethgoog https://archive.org/details/observationssir02bethgoog https://archive.org/details/hawkinsvoyagesd00hawkgoog https://archive.org/details/hawkinsvoyagesd00figugoog Related documents: https://doi.org/10.1111/j.1753-4887.1986.tb07575.x (Nutrition Classic) https://en.wikipedia.org/wiki/Richard_Hawkins 52 Part I: CHAPTER I. A critical history of the different accounts of this disease https://archive.org/details/b30511902/page/n21/mode/2up p.11 (3rd p.1) In the first accounts given us of this disease, by Ronsseus, Echthius, and Wierus, it is surprising to find, not only an accurate description of it, but an enumeration of almost all the truly antiscorbutic medicines that are known to the world even at this day. The first authors on the scurvy, Ronsseus and Echthius, though cotemporary, wrote separately, without having the benefit of seeing each others works. p.14 (3rd p.4-5) … the putrid gums and swelled legs were the most certain and only characteristic signs of it [scurvy]. [see section “Strengths and limitations of the descriptions of scurvy symptoms by early authors” for Lind’s comments on Eugalenus and Willis, and see Lind’s entire text for details] 53 Part I: CHAPTER III. Of the distinction commonly made into a land and sea scurvy https://archive.org/details/b30511902/page/28/mode/2up p. 52 (3rd p. 29) This disease has been always most common at sea. It is well known there in the present age, by reason of the frequent voyages to the most distant parts of the world. The symptoms, though numerous, are yet observed to be regular and constant ; so that the most ignorant sailor, in the first long voyage, becomes well acquainted with it… p. 53-54 As to the pathognomonic signs of the disease… putrid gums, swelled legs, and spots, accompanying each other, and in their progress usually attended with rigid tendons in the ham, are observed in no other distemper. It is also peculiar to it, that persons thus afflicted, though otherwise apparently healthful, are upon the least motion, or exertion of strength, apt to faint, and do often suddenly drop down dead. (3rd p. 29-30) 1st, As to the pathognomic signs of this disease ; If we compare its symptoms as described by Echthius, Wierus, and all authors till the time of Eugalenus, with the accounts given of them in books of voyages, particularly the extraordinary narrative of what happened in Lord Anson’s voyage round the world, we shall perceive an entire agreement in the essential signs of the distemper, and appearances so singular as are not to be met in any other. … Forrestus, though he had frequent opportunities of seeing it in sailors, yet in all his histories gives us but one case of a mariner. His most faithful accounts of this malady, are illustrated by patients who had always lived at land ; some of whom must have been afflicted in a very high degree, as they dropped down dead suddenly, to the surprise of their relations… p.54 (3rd p. 30-31) It is indeed remarkable, that the first just description published of this disorder in Europe, was in an account of it raging in besieged towns, by the historian Olaus Magnus59, where it was attended with such symptoms as occur always at sea. p.59-63 (3rd p. 36-40) It may be believed, that there are few people who have had the opportunities of reading more upon this subject than I have done ; and that there are few books or observations published upon the disease, that have not fallen under my inspection… I did not find two authors agree who founded their doctrine upon facts and observations. I observed, that ten different practitioners pronounced ten cases to be scorbutic, which, upon examination, did not bear the least resemblance or analogy to each other. … might have multiplied absurdities, in like manner as every private practitioner does, who thinks he has a right to term what he pleases a scurvy… … We shall however lay before them a view of the fatal effects produced by the use of such vague and indefinite terms. 1st, On young practitioners and students in physic ; who being provided with such a general name as that of the scurvy, comprehending almost all diseases, think themselves at once acquainted with 59 Olaus Magnus (1555) Historia de gentibus septentrionalibus. 54 the whole art of medicine ; as they may be furnished with numerous cures for it from the many Pharmacopœias with which the present age abounds. 2dly, Older practitioners, by referring many various and uncommon diseases to such imaginary causes, deprive the world of the true improvement of their art : which can only be expected from accurate histories of different cause, faithfully and honestly stated… 3rdly, and lastly, It has a most fatal influence on the practice. Thus the original and real disease has been lost and confounced amidst such indefinite distinctions and divisions of it, that it is sometimes not known by the best practitioners, when it really occurs. Part II: CHAPTER I. Mr Ives’s journal p.106-111 (3rd p.89-96) The following abstract from the ingenious Mr Ives’s journal, containing a history of diseases that occurred on board the Dragon, serves to confirm many things which have been advanced. 1743. July. We have been free from the scurvy ever since the latter end of August… November. Partly at sea, partly at Gibraltar. From the 1st to the 10th fresh easterly winds blew often, with rain. The whole month was squally60, but dry towards the latter end. On the 8th day, 6 or 8 people were taken with pains in their head, shiverings, and sometimes a vomiting. The next day they were feverish. On the 3rd or 4th they complained of an universal prickling under the skin, and had a short uneasy cough. On the 5th of 6th they were covered with little red spots like flea-bites, with sore and watery eyes. On the 8th they sweated plentifully, or had a looseness ; and then they were sure to do well soon ; though some spit, and others were relieved by urine… December. Lay at Gibraltar. It was in general a cold, wet stormy month. The sick-list contained various, but not material complaints. Towards the latter end of it we had appearances of an approaching scurvy, although at Gibraltar. Sent 22 to hospital. On the 8th day we left Gibraltar, growing daily worse in the scurvy. On the 10th day 50 scorbutic patients were on the sick-list, and by 20th they were increased to 80. Many of them were now extremely bad, with hard contracted limbs, ulcerated legs, rotten gums, stinking breath, offensive stools, shortness of breath &c. On the 30th of January my list stood thus. Very bad in scurvy 55. Scorbutic fluxes 6. Scurvy with cough 10. Scurvy with ulcers 10. Scorbutic asthma 1. Scorbutic hæmoptoe 1… 1745… on the 20th of November, I gave to every scorbutic patient one China orange, and three apples ; and continued to do so daily till the 5th of December, when the apples being all gone, they had only the continuance of an orange, which lasted to the 7th of December… November 29. The scorbutic people in general mend much. Those whose limbs were contracted grew pliable ; their rotten gums became sounder ; shortness of breath, &c. better. 60 Turbulent, rough 55 Part II: CHAPTER II. The diagnostics, or signs (The diagnostics, or symptoms in the 3rd ed) https://archive.org/details/b30511902/page/98/mode/2up p. 113-117 (3rd p. 98-104) In order to observe greater accuracy in the description of a disease attended with so many and various symptoms, these might have been properly enough ranged under three classes… But, for the sake of greater perspicuity, I chuse rather to describe the symptoms in the order in which they generally appear, and as peculiar to the several stages of the disease ; and shall distinguish, as I go along, those which are more constant or essential, from the less frequent or adventitious. The first indication of the approach of this disease, is generally a change of colour in the face, from the natural and usual look, to a pale and bloated complexion ; with a listlessness to action, or an aversion to any sort of exercise. When we examine narrowly the lips, or the caruncles61 of the eye, where the blood vessels lie most exposed, they appear of a greenish cast. Mean while, the person eats and drinks heartily, and seems in perfect health ; except that his countenance and lazy inactive disposition, portend a future scurvy. This change of colour in the face, although it does not always preceed the other symptoms, yet constantly attends them when advanced. Scorbutic people for the most part appear at first of a pale or yellowish hue, which becomes afterwards more darkish or livid. Their former aversion to motion degenerates soon into an universal lassitude, with a stiffness and feebleness of their knees upon using exercise ; with which they are apt to be much fatigued, and upon that occasion subject to a breathlessness or panting. And this lassitude, with a breathlessness upon motion, are observed to be among the most constant concomitants of the distemper. Their gums soon after become itchy, swell, and are apt to bleed upon the gentlest friction. Their breath is then offensive ; and upon looking into their mouth, the gums appear of an unusual livid redness, are soft and spungy, and become afterwards extremely putrid and fungous ; the pathognomonic sign of the disease. They are subject not only to a bleeding from the gums, but prone to fall into hæmorrhages from other parts of the body. Their skin at this time feels dry, as it does through the whole course of the malady. In many, especially if feverish, it is extremely rough ; in some it has an anserine appearance ; but most frequently it is smooth and shining. And, when examined, it is found covered with several reddish, bluish, or rather black and livid spots, equal with the surface of the skin, resembling an extravasation under it, as it were from a bruise. These spots are of different sizes, from the bigness of a lentil to that of a handbreadth, and larger. But the last are more uncommon in the beginning of the distemper ; they being usually then but small, and of an irregular roundish figure. They are to be seen chiefly on the legs and thighs ; often on the arms, breast, and trunk of the body ; but more rarely on the head and face. Many have a swelling of their legs ; which is first observed on their ancles towards the evening, and hardly to be seen next morning : but, after continuing a short time in this manner, it gradually advances up the leg, and the whole member becomes œdematous ; with this difference only in some, that it does not so easily yield to the finger, and preserves the impression of it longer afterwards than a true œdema. 61 A small fleshy excrescence 56 These are the most constant and essential symptoms of this malady in the progress of its first stage. But a diversity is sometimes observed in the order of their appearance. Thus, when a person has had a proceeding fever, or a tedious fit of sickness, by which he has been much exhausted, the gums for the most part are first affected, and a lassitude constantly attends ; whereas, when one has been confined from exercise by having a fractured bone, or from a bruise or hurt, these weak and debilitated parts become almost always first scorbutic. As for example, if a patient labours under a strain of the ancle, the leg, by becoming swelled, painful, and œdematous, and soon after covered with livid spots, gives the first indication of the disease. And as old ulcers on the skin are very frequent among seamen, in this case likewise the legs are always first affected, and these ulcers put on the scorbutic appearance, although the patient seems otherwise perfectly healthy, and preserves a fresh good colour in his face. The distinguishing characteristics of scorbutic ulcers are as follow. They afford no good digestion, but a thin, fœtid, sanious62 stuff, mixed with blood ; which at length has the true appearance of coagulated gore63 lying caked on the surface of the ulcer, and is with great difficulty wiped off, or separated from the parts below. The flesh underneath these sloughs feels to the probe soft or spungy, and is very putrid. No detergents or escharotics are here of any service : for though such sloughs be with great pains taken away, they are found again at next dressing, where the same sanguineous64 putrid appearance always presents itself. Their edges are generally of a livid colour, and puffed up with excrescencies of proud flesh arising from below under the skin. When too tight a compression is made, in order to keep the fungus from rising, they are apt to have a gangrenous disposition ; and the member never fails to become œdematous, painful, and for most part spotted. As the disease increases, they at length come to shoot out a soft bloody fungus, which the sailors express by the name of bullocks65 liver : and indeed it has a near resemblance, in consistence and colour, to that substance when boiled. It often rises in a night’s time to a monstrous size ; and although destroyed by cauteries, actual or potential, or cut smooth with a bistory,66 (in which case a plentiful hæmorrhage generally ensues), is found at next dressing as large as ever. They continue however in this condition a considerable time, without affecting the bone. The slightest bruises and wounds of scorbutic persons degenerate into such ulcers. Their appearance, on whatever part of the body, is so singular and uniform, and they are so easily distinguished from all others, by being so remarkably putrid, bloody, and fungous, that we cannot here but take notice of the impropriety of referring most of the inveterate and obstinate ulcers on the legs, with very different appearances, to the scurvy ; which are generally best cured by giving mercurial medicine : whereas that medicine, in a truly scorbutic ulcer, is the most dangerous and pernicious that can lie administered. p.118-119 (3rd p. 104-105) But to proceed : The first remark to be made upon this disease, is, that whatever former ailment the patient has had (especially rheumatic pains, aches from bruises, hurts, wounds, &c.), or whatever present disorder he labours under ; upon being afflicted with this distemper, his former and old complaints are renewed, and his present malady, whatever it may be, rendered worse. Scorbutic people, as the disease advances, are seldom indeed free from complaints, especially of 62 Consisting of a thin mixture of serum and pus with a slightly bloody tinge 63 Blood 64 Containing blood 65 A young male cow 66 Scalpel 57 p.127-128 (3rd p.119-120) Lieutenant John A of marines, aged 40, was formerly extremely healthy, though much at sea ; where he had seldom or never eat of salt provisions, officers tables being generally well provided with better fare. He had lately returned from some Channel cruises to the westward ; where, as usual, he had not eat of any thing salt, having a natural aversion to such food. One day, to his great surprise, he observed on about the middle of one of his legs a considerable bunching up from over the tibia ; and taking down his stocking, found a bluish insensible swelling. Next morning it was increased to the size of a large walnut ; and in two or three days the skin broke, and it became a genuine scorbutic ulcer, with the liver-like fungus. After which began also other symptoms ; change of colour, tightness in the breast, rotten gums, and, what was very threatening to his life, an obstinate constipation of the bowels, attended with intolerable gripings. He took country-lodgings ; and, being properly treated, in about six weeks, or two months, recovered. p.128-132 (3rd p.120-125) Letter from Dr James Grainger, surgeon to Lt-Gen. Pultney’s regiment I have extracted from my notes the following brief description of the scurvy, which prevailed ann. 1751-2, among the six companies of our regiment quartered at Fort-William. I had then an opportunity of seeing it in no less than near 100 patients ; and must ingenuously own, it was there I learned my first lesson upon the disease. My predecessor had not informed me, that this was a disorder of that garrison ; it was a subject of which I had read much, but knew little ; so that the first I treated, had well nigh fallen a martyr to improper prescription. The pains this soldier complained of, appeared to me rheumatic. This I the more easily gave into, as at that time this disease was actually frequent. He was bled, and treated accordingly ; upon which his pains grew worse than ever, and no wonder. I began to talk seriously to him, and upbraided him with having pretended complaints more than real. But he soon gave me evident marks of real distress. Livid spots on the thighs, rotten, bleeding gums, and his stinking breath, quickly convinced me, that I had mistaken his case, and consequently his method of cure. The scurvy now began to spread, and I profited by my former inattention. Its first appearances were, lassitudo, breathlessness upon the least quickness of motion, and a taste in the mouth peculiarly disagreeable : which were soon followed by rotten, spungy, painful gums, bleeding from the slightest touch ; fœtid breath ; pains always of their thighs, frequently of their legs, sometimes of their loins, seldom of their arms. All these parts were sometimes discoloured with purple maculæ, which, as the malady increased, grew black and broad. The anterior parts of the legs and thighs chiefly suffered… their faces grew strangely sallow, their teeth loosened, palate and fauces ulcerated, asthma increased ; they fell away, slept little, old ulcers broke out again, cried out when turned in bed, and sometimes fainted upon motion of their body. What surprised me most, was, that their appetite, even in these deplorable circumstances, was not greatly impaired ; and that none of them could properly be said, though thirsty, to be in a fever. All of them were rather costive, and their urine, though not copious, was always vastly fœtid and thick, 64 in those especially who complained of their loins. Most of them were continually spitting, and a small quantity of mercury occasioned a dreadful salivation. A soldier who laboured under the venereal disease, used but a dram of crude mercury, by way of unction, one evening. Next morning I found him in a true mercurial salivation. The spitting went on, increasing until the tenth day ; when the inside of his mouth, lips, and cheeks, became monstrously swelled. The stench of his mouth was intolerable to all about him. He every day spit out a quantity of fœtid blood, part of his gums, and teeth. He lost almost all the latter ; and what was very remarkable, they were found preternaturally enlarged. His urine was extremely fœtid, thick, and almost blackish. He often fainted away. In short, the poor fellow was reduced to the most deplorable condition, and with great difficulty escaped. It was three months afterwards before he was fit for duty. The scurvy began in March, raged in April, declined in May, and left us before the middle of June. Ninety during that period had scurvies at Fort-William ; while there were only two soldiers out of four companies seized with it at Fort-Augustus, and but one in a Captain’s command at the barracks of Bernera. These three indeed were very bad. No officer had it in any one of these garrisons. I imputed the malady to the following causes. 1st, Constant moist, rainy weather. 2nd, Salt provisions from December till near the end of May, salt butter, cheese, oat-meal. 3rd, Few or no vegetables : little, bad, or no milk. 4th, Indifferent water. 5th, Hard duty. The 1st, 3d, 4th, 5th causes prevailed less at Fort-Augustus and Bernera ; and therefore these places had not their proportion of scorbutical patients.—— This disease is in several parts of Scotland called by the name of the black leg. It has often been very epidemic and fatal to the miners at Strontian in Argyleshire. Not long ago many of them died of it, with this remarkable symptom, that the hypochondria and lower belly were at length covered with large scorbutic maculæ. This, Dodonæus, a good author on the scurvy, long ago observed to be a mortal symptom. I am informed of a certain Noble family, whose seat in the country is bleak, and exposed to the sea, where they have been universally afflicted with spungy, rotten gums, swelled legs, ulcers, &c. Lately a gentleman confined in jail at Edinburgh, complained of a swelling of his legs. Upon examination, they were found covered with black and bluish spots ; soon after his gums became extremely putrid and fungous. His case being neglected, a caries of the lower jaw ensued ; for which he was put under my care. A navy-surgeon residing in Fife, in passing by Backhaven, was desired to visit two poor fellows who were extremely bad. He found them in a miserable condition indeed ! Their gums were monstrously putrid, their bodies spotted, and they were altogether deprived of the use of their limbs, by a swelling in the joint of the knee ; in one of them the tendons in the ham were contracted, and quite indurated. The gentleman acquainted them with the nature of their malady, and by a proper prescription restored them soon to health. 65 (3rd p.125-127) I have been favoured with several letters by different gentlemen, giving an account of the unfortunate and sometimes fatal errors they have fallen into by mistaking this disease. But as I chuse now rather to publish my own faults than the misfortunes of others, I must ingenuously own (hoping it may be for the future benefit of practitioners) that before I had learned the nature and symptoms of the scurvy from observation, two patients fell under my cure ; in one of whom the disease proved fatal, and in the other extremely tedious, owing in all probability to improper treatment. At least were such cases to occur to me at present, I would treat them in a very different way. A gentleman, after a tedious salivation, in which he had used a large quantity of mercury, was reduced to great weakness of body, and afflicted with a tremulous77 disorder of his limbs, for which he took several doses of prepared crude antimony. Though seemingly much mended in his health and looks, he soon after became afflicted with a swelling of his legs ; and as his teeth had not been fastened, several of them dropped out. He was put upon a course of restoratives viz. a bitter steelwine with an electary of the bark and gum guajac. After using them for ten days he was seized with a purging, upon which account they were laid aside, and astringents with ol. vitrioli prescribed. Soon after this, the tendons in the ham became so rigid, that his legs were bent quite back, and in this pitiful condition he was deprived of the benefit of all exercise. When the flux had left him, recourse was again had to his former reiterative medicines. Ointments, steams, and fomentations were used to his contracted joints, but all to no purpose. At this time the putrefaction in the mouth was so great, that a caries of the jaw bone was suspected. The disease still gained ground, he was suddenly seized with a large watery swelling of the scrotum and a hardness and fullness of the belly. An infusion of mustard seed, nutmegs and salt of wormwood in white-wine was administered. Various other unsuccessful methods were tried, but he died in about three months after his having been first afflicted with the scurvy. Another patient, who had kept the house for some days with a severe cough and disorder in the breast, was, upon these complaints leaving him, seized with rheumatic pains in his arms and legs, being otherwise in perfect health. He took several sweating medicines without any sensible relief ; and for a considerable time thirty drops of ol. tereb. three times a-day; and afterwards half a drachm of flor. sulph. twice a-day : notwithstanding which the pains encreased, and became more universal. He at length observed his skin all over spotted. The spots were of a purple colour, and became daily more numerous ; the pains in some parts were relieved by the eruptions, but he now complained much of an universal weariness and an increase of the pains in his joints. He underwent a course of æthiops mineral and g. guajac with decoct. lignor. Blisters were applied to his joints. A new symptom appeared, viz. a sort of bloody flux, but not attended with pain. He afterwards became greatly dejected in mind, and was subject to faintings. All this time the scorbutic spots continued out upon his body. Another person being upon this occasion consulted, the case was pronounced to be nervous. Castor. sal. C. C. cephalic pills, tinct. sacra, epispastics, &c. were prescribed without procuring more than a temporary relief. At last, upon hearing some unexpected good news, which obliged him to go into the country, he found himself considerably relieved ; and after having undergone a very tedious course of medicines, was soon recovered by change of air, warm weather, proper exercise, drinking whey, and taking a gentle laxative when needful. 77 Shaking, trembling 66 Extract of a letter received from Dr. Huxham, late physician in Plymouth. [3rd p.128-129] In answer to your question, whether we meet with many truly scorbutic cases in Devonshire and Cornwall, amongst those who constantly live at land, I assure you we meet with very many patients of that kind… In these places the scurvy is as it were endemic from the lower degrees of it, viz. pustular eruptions, itching spungy gums, sallow complexion, lassitude and inactivity, weak pulse, black and blue spots up and down the arms, legs, thighs, &c. a foul greasy urine loaded greatly with salinosulphureous salts, to its greatest degree of virulence, accompanied with fungous, livid, bleeding gums, horribly stinking breath, a sallow bloated countenance, vast dejection of spirits and faintings, a swelled belly, gripes, the bloody flux, profuse hæmorrhages from various parts, a difficulty of breathing, especially upon the least motion, very-large black, blue, yellow spots, swellings, contractions, and stiffness of the lower limbs, and sordid, spungy, livid ulcers on the legs, &c. with a load on the breast, and an anxiety scarce to he expressed. 67 Part II: CHAPTER III. The prognostics https://archive.org/details/b30511902/page/128/mode/2up p. 133-135 (3rd p. 129-132) Persons who have been weakened by other proceeding distempers, such as fevers or fluxes ; or by tedious confinement and cures, as those who have undergone a salivation, are of all others most subject to this disease. Intermitting fevers in a particular manner dispose the constitution to it. Those who have formerly been afflicted with it, are much more liable to it, in parallel circumstances, than others. … when confined to bed, or prevented from using exercise, by swelling of the legs, weakness, or from other causes, the evil, where no green vegetables or fruits can be procured, infallibly increases ; and when it is advanced to what I have called the second stage, is not to be cured without them. The symptoms related to occur in the last stage, are of all others the most dangerous ; viz. oppression on the breast, obstinate costiveness, stitches in the side [sharp pains in the side; 3rd ed], and frequent faintings ; but especially great difficulty of breathing. At sea, where no greens, fresh meats, or fruits are to be had, the prognostics in this disease are sometimes deceitful ; for people that appear to be but slightly scorbutic, are apt to be suddenly and unexpectedly seized with some of its worse symptoms. Their dropping down dead upon an exertion of their strength, or change of air, is not easily foretold ; though it generally happens after a tedious confinement in a foul air. The first promising appearance in bad cases, when fruits or greens are first allowed, is the belly becoming lax ; these having the effect of very gentle physic : and if in a few days the skin becomes moist and soft, it is an infallible sign of their recovery ; especially if they bear gentle exercise, and change of air, without being liable to faint. If the vegetable aliment restores them in a few days to the use of their limbs, they are then past all danger of dying at that time of this disease ; unless afflicted with the scorbutic dysentery, or the pectoral disorder. These two often prove fatal, and are the most obstinate to remove of all the scorbutic symptoms. The blackness of the skin, or spots, upon recovery, go off nearly in like manner as other ecchymoses, growing gradually yellow, from the circumference to the center ; the natural colour of the skin returning in the same manner. A deep scorbutical taint, where the breast has been much affected, often ends in a consumption. Others have contracted a dropsical disposition from this disease ; or, what is more frequent, swelled, œdematous, and ulcerated legs. Such persons are likewise subject, in different periods of their life afterwards, to chronic rheumatisms, pains and stiffness in their joints ; and sometimes to cutaneous eruptions, or a foulness of the skin. 68 (3rd p.136-137) On the 21 June, 1760, John Macgottin was landed at Haslar, from the Richmond frigate, who had laboured under the scurvy above 12 months… a gnawing pain in his ankle. That joint grew so extremely weak, that he compared himself to a person, who after a long journey on foot, could not stand or walk. His legs swelled much towards evening. Other scorbutic signs appeared afterwards, especially a boil upon his right knee, which discharged blood and purulent matter. The disease continued to harass him till the frost began in winter, when he thought himself somewhat better. But in March, 1760, when the thaw came on, the scurvy suddenly attacked him, with greater violence than ever… This poor man, upon the least motion of his body, even in bed, fell into long and dangerous fits of fainting, attended with violent sweats, which hung upon him in large drops, warm at first, then turning cold and clammy. His whole skin was tinged with yellow. The pain in his back was troublesome, but not so acute as the pains in his lower extremities, which prevented his having any sleep in the night. His legs were much extenuated, of a dark red colour, and overspread with elevated spots of the same hue. His ancles were of a dark livid die, and hard. This hardness and colour extended over the soles of his feet even to his toes, which were quite black. He had also a cough, and the scorbutic pain of the breast, in its usual seat. His face was bloated, and swelled. The forepart of his gums was ulcerated, corroded and wasted away ; the other parts were spungy, jagged, and detached from his teeth. Notwithstanding this severe accumulation of complicated misery, his disease soon took a favourable turn, and in two months he was perfectly reestablished in health, and discharged from the hospital. 69 Part II: CHAPTER IV. The prophylaxis, or means of preventing this diseases, especially at sea https://archive.org/details/b30511902/page/138/mode/2up p.145-148 (3rd p. 149-153) [the “Lind trial”]78 The following are the experiments. On the 20th of May 1747, I took 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 their 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. [but] Two of the worst patients, with the tendons in the ham rigid (a symptoms none of the rest had) were put under a course of sea-water79 … Two others had each two oranges and one lemon given them every day. These they eat with greediness, at different times, upon empty stomach. They continued but six days under this course, having consumed the quantity that could be spared… The consequence was, that the most sudden and visible good effects were perceived from the use of oranges and lemons ; one of those who had taken them, being at the end of six days fir for duty… [There were 4 additional pairs with different treatments, see Lind’s text through the links] The consequence was, that the most sudden and visible good effects were perceived from the use of the oranges and lemons ; one of those who had taken them, being at the end of six days fit for duty. The spots were not indeed at that time quite off his body, nor his gums sound ; but without any other medicine, than a gargarism of elixir vitriol, he became quite healthy before we came into Plymouth, which was on the 16th of June. The other was the best recovered of any in his condition ; and being now deemed pretty well, was appointed nurse to the rest of the sick. 78 The Lind trial and some discussions of it; see also the longer list of papers about Lind above: https://archive.org/details/b30511902/page/149/mode/1up https://archive.org/details/treatiseonscurvy1772lind/page/149/mode/1up https://archive.org/details/bim_eighteenth-century_a-treatise-on-the-scurvy_lind-james_1772/page/149/mode/1up https://babel.hathitrust.org/cgi/pt?id=ucm.5320216006&seq=171 https://www.jameslindlibrary.org/lind-j-1753 https://doi.org/10.1177/014107689709000118 https://doi.org/10.1017/S0025727300020469 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1081662 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1644345 79 In the current context we would consider that “sea water” in this kind of trial is a negative control. However, Lind writes elsewhere: “… giving scorbutic people salt water has been often tried ; and some have thought they received benefit from it. See chap. IV” (1st ed, footnote p.72; 3rd ed. p.47). “… a very false opinion, that sea-salt breeds the scurvy : the contrary of which has been fully demonstrated chap. I and is confirmed by numberless instances of giving salt water in very bad scurvies, both at sea and land, with great benefit to the patient. See Mr Ives’s letter, p. 146. Dr Grainger’s, chap. V.” (1st ed, footnote p.160; 3rd ed. p.172). “Several mineral waters in England… have gained reputation of curing inveterate scurvies… Drinking the sea water, with sometimes the addition of a few drops of the vinum-antimonale, and bathing in it, as also the use of warm sea water baths, have proved serviceable” (3rd ed, p.201-202). Further, “worst patients” in Lind’s trial means that Lind did not intend to distribute trial patients evenly by severity. Thus, they were not “as similar as I could have them”. 70 p.148-150 (3rd p.153-155) It may be now proper to confirm the efficacy of these fruits by the experience of others. The first proof that I shall produce, is borrowed from the learned Dr Mead. One year when that brave Admiral Sir Charles Wager commanded our fleet in the Baltic, his sailors were terribly afflicted with the scurvy : but he observed, that the Dutch ships then in company were much more free from this disease. He could impute this to nothing but their different food, which was stock-fish and gort ; whereas ours was salt fish and oat-meal. He was then come last from the Mediterranean, and had at Leghorn taken in a great quantity of lemons and oranges. Recollecting, from what he had often heard, how effectual these fruits were in the cure of this distemper, he ordered a chest of each to be brought upon deck, and opened, every day. The men, besides eating what they would, mixed the juice in their beer. It was also their constant diversion to pelt one another with the rinds, so that the deck was always strewed and wet with the fragrant liquor. The happy effect was, that he brought his sailors home in good health. I have been favoured upon this occasion, by different gentlemen, with many instances of the like good effects of these fruits in this disease at sea ; particularly by Mr Francis Russel, in a cruise performed by the Princess Caroline off the islands of Sardinia and Corsica ; where, according to his relation, some of these fruits got at Vado, preserved great part of the crew, which otherwise must undoubtedly have perished. An ingenious surgeon of great merit and experience in the Guernsey when extremely distressed by the scurvy, has the following observation in his letter upon it. I have great reason to believe, that several lives were absolutely preserved, when we were at sea, by a lemon squeezed into six or eight ounces of Malaga wine mixed with water, and given twice a day. I am informed, it was principally oranges which so speedily and surprisingly recovered Lord Anson’s people at the island of Tinian. Of which that noble, brave, and experienced commander was so sensible, that, before he left the island, one man was ordered on shore from each mess to lay in a stock of them for their future security. My ingenious friend Mr Murray, who has favoured me with so many useful observations upon this disease ; and has had the greatest opportunities of being acquainted with it, as he for a considerable time attended the naval hospital at Jamaica whilst our great fleets were in the West Indies, and was likewise surgeon of the Canterbury, expresses himself thus in his letter. As to oranges and lemons, I have always found them, when properly and sufficiently used, an infallible cure in every stage and species of the disease, if there was any degree of natural strength but left ; and where a diarrhæa, lientery, or dysentery, were not joined to the other scorbutic symptoms. Of which we had a most convincing proof, when we arrived at the Danish island of St Thomas ; where fifty patients belonging to the Canterbury, and seventy to the Norwich, in all the different stages of this distemper, were cured, in little more than twelve days, by limes alone ; where little or no other refreshments could be obtained. It was reasonable to ascribe this to the eminent virtues of these fruits ; as it is well known, and daily experienced, that without such remedies scorbutic people will infallibly die in the purest land-air. 71 But what cures such deplorable cases, must still more powerfully prevent them. Perhaps one history more may suffice to put this out of doubt. p.151-152 (3rd p.155-157) Perhaps one history more may suffice to put this mater out of doubt. In the first voyage made to the East Indies, on account of the English East-India company, there were employed four ships, commanded by Captain James Lancaster80 their General, viz. the Dragon having the General and 202 men, the Hector 108 men, the Susan 82, and the Ascension 32. They left England about the 18th of April ; in July the people were taken ill on their passage with the scurvy ; by the 1st of August, all the ships, except the General's, were so thin of men, that they had scarce enough to hand the sails ; and, upon having a contrary wind for fifteen or sixteen days, the few who were well before, began also to fall sick. Whence the want of hands was so great in these ships, that the merchants who were sent to dispose of their cargoes in the East Indies, were obliged to take their turn at the helm, and do the sailors duty, till they arrived at Saldania ; where the General sent his boats, and went on board himself, to assist the other three ships ; who were in so weakly a condition, that they were hardly able to let fall an anchor, nor could they hoist out their boat without his assistance. All this time the General’s ship continued pretty healthy. The reason why his crew was in better health than the rest of the ships, was owing to the juice of lemons ; of which the General having brought some bottles to sea, he gave to each, as long as it lasted, three spoonfuls every morning fasting. By this he cured many of his men, and preserved the rest : so that although his ship contained double the number of any of the others ; yet (through the mercy of God, and to the preservation of the other three ships) he neither had so many men sick, nor lost so many as they did. Here indeed is a remarkable and authentic proof of the great efficacy of juice of lemons against this disease ; as large and crouded ships are more afflicted with it, and always in a higher degree, than those that are small and airy. This little squadron lost 105 men by the scurvy. Upon its afterwards breaking out among them when in the East Indies, in a council held at sea it was determined, to put directly into some port where they could be supplied with oranges and lemons, as the most effectual and experienced remedies to remove and prevent this dreadful calamity. p.153 (not in the 3rd ed) … And here we may again observe the fatal consequence of confounding this malady with others. Legions of distempers (according to Willis and others) very different from the real and genuine scurvy, have been classed under its name : and because the most approved antiscorbutics fail to remove such diseases, hence we are told by authors, that it is the masterpiece of art to cure it. But 80 The voyages of Sir James Lancaster. https://archive.org/details/voyagesofsirjame00markrich/page/60/mode/2up (p.61-62) https://archive.org/details/cihm_33135/page/n99/mode/2up (p.61-62) https://archive.org/details/voyagessirjames00markgoog/page/n96/mode/2up (p.61-62) https://archive.org/details/voyagessirjames01markgoog/page/n97/mode/2up (p.61-62) https://archive.org/details/in.ernet.dli.2015.39239/page/n95/mode/2up (p.61-62) https://archive.org/details/dli.ministry.07086/page/78/mode/2up (p.79-80) https://archive.org/details/TheVoyagesOfSirJemesLancasterToBrazilAndTheEastIndies15911603/page/n125/mode/2up 72 this is contradicted by the daily experience of seamen, by the journals of our sea-hospitals, and by the yearly experience of our English East-lndia ships at St. Helena, and the Cape of Good Hope. So that nothing can be more absurd, than to object against the efficacy of these fruits in preventing and curing the real scurvy, because they do not cure very different diseases. p.155 But these fruits have this peculiar advantage above any thing than can be proposed for trial, that their experienced virtues have stood the test of near 200 years.81 p.155 As oranges and lemons are liable to spoil, and cannot be procured at every port, nor at all seasons in equal plenty ; and it may be inconvenient to take on board such large quantities as are necessary in ships for their preservation from this and other diseases ; the next thing to be proposed, is the method of preserving their virtues entire for years in a convenient and small bulk. It is done in the following easy manner… 82 p.160 Every common sailor ought to lay in a stock of onions. I never observed any that used them fall into the scurvy at sea. p.165-166 (3rd p.177-179) But it appears by the experience of the northern American colonies, as also of several countries up the Baltic in Europe, &c. that genuine spruce beer is, above all others, not only an effectual preservative against it, but an excellent remedy. The antiscorbutic virtue of the fir was, like many other of our best medicines, accidentally discovered in Europe. When the Swedes carryed on a war against the Muscovites, almost all the soldiers of their army were destroyed by the true marsh or marine scurvy, having rotten gums, rigid tendons, &c. But a stop was put to the progress of this disease, by advice of Erbenius the King’s physician, with a simple decoction of fir-tops… I am inclined to believe, from the description given by Cartier of the ameda tree, with a decoction of the bark and leaves of which his crew was so speedily recovered, that it was the large swampy American spruce tree. 81 In many other places Lind suggest that the cause of scurvy is not the lack of fruit and vegetables, but that is not the focus of this document. 82 Lind’s method of concentrating fruit causes degradation of vitamin C. See: Hughes RE (1975) James Lind and the cure of scurvy: an experimental approach. Med Hist. https://doi.org/10.1017/s0025727300020469 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1081662 73 Other dissections described in Lind’s texts: PART III: CHAPTER II: 1750 M. Gmelin PART III: CHAPTER II: 1764 L. Rouppe POSTRIPT to the 3rd ed (1772) SECTION I: Appearances on dissection of scorbutic bodies. 80 PART II: CHAPTER VIII. The nature of the symptoms, deduced and explained from the foregoing theory and dissections https://archive.org/details/b30511902/page/244/mode/2up p.232 (3rd p.245) The symptom most commonly preceeding the others in this disease, is a preternatural change of colour in the face… p.233-234 (3rd p.246) But in the case of scorbutic people, it is somewhat singular, and peculiar to them, that though when at rest they find themselves quite well ; yet, upon the least exercise, they are subject, at first, to a panting and breathlessness ; which, as the disease increases, degenerates into a proneness to faint ; and, lastly, in the height of the malady, upon using exercise, or an exertion of their strength, or upon being exposed to a sudden change of air, they are apt to drop down dead. p.235 (3rd p.247) When the body is at rest, the circulation is languid and slow: the blood then, in a small quantity, glides gently through the lungs, notwithstanding the obstruction in them. But when, upon using exercise, or an exertion of strength, the velocity of the blood is accelerated, and a much greater quantity, viz. that which, when at rest, was almost stagnating in the veins, is at once returned into the right cavities of the heart, and from thence into the lungs ; the weakened and obstructed vessels of the lungs not being able so quickly to transmit so great a quantity, the blood is necessarily accumulated in the sinus venosus, right auricle and ventricle of the heart : which causes a breathlessness and panting ; that is, an effort is made by all the powers subservient to respiration, to dilate the breast fuller and more frequently, for the passage of this increased quantity of blood. p.236-238 (3rd p.248-250) … the passage of the blood through the lungs must still be more straitened. Hence, upon the least motion of the body, by which the circulation is quickened, and a greater quantity of blood sent at once into the heart, the heart becomes in such cases not able to overcome the resistance it meets with in forcing the blood through the lungs, as well as the weakened unelastic arteries. Whence, as before observed, the blood being accumulated, and stagnating as it were, in the cavities of the heart, there must follow an almost entire stoppage of the circulation for some time, a pause and cessation of the vital motions for a little ; that is, the patient must faint away, till, by the exertion of the vital principle, and the heart being evacuated by the person’s lying at rest, the circulation is again quickened, and he recovers. Lastly, it appears by the weakness and feebleness of the pulse, and many other symptoms in this disease, as likewise from the known effect of putrefaction on animal bodies, by which the fibres are always rendered softer and tenderer, that the whole system of solids is in the most relaxed and weakened condition. Even the heart itself was found putrid, (N° 2), whose force to circulate the blood is not indefinite, more than its cavities, which can contain only a proportioned quantity. The first is certainly here greatly impaired ; while the latter, or its cavities, were found preternaturally weakened and dilated, (N° 6). In this state, such people are apt to drop down dead upon an exertion of their strength, or from exercise, but especially upon being exposed to a sudden change of air ; that is, by removing them at once from the warm and moist air in the hold of a ship, into a colder, drier, and purer air. For the effect of this is, to constringe the whole external habit of the body, and to drive the blood at once with great force from thence towards the heart ; at which time the 81 velocity, as well as quantity of it, is increased in the internal parts. So that the heart is not able to overcome the resistance it meets with in the weak and unsound lungs, (whose vessels are also straitened by the contact of such fresh air) ; nor in the arteries, which will be in proportion to the quantity of blood with which they remain distended. But the weak unelastic arterial system is not here able to contract and propel the blood in their canals. On the contrary, the cutaneous vessels being thus constringed by the external air, the blood may perhaps have, as it were for an instant, a retrograde motion towards the heart, which this debilitated muscle (N° 2) cannot overcome. Hence such people drop down dead suddenly, without any other visible cause of their death found upon dissection, (N° 6), than the weakened auricles of their heart aneurismatic, and distended with blood. They are observed to have a panting or breathlessness for about half a minute before they expire. In Lord Anson’s crew it was remarked, that a straitness of the breast, with an obstinate costiveness, was one of the most dangerous and fatal symptoms. p.239 (3rd p.251) The pathognomonic signs of the scurvy, which are putrid gums, a stinking breath, and loosening of the teeth… 82 PART III: CHAPTER I. Passages in ancient authors, supposed to refer to the scurvy ; together with the first accounts of it https://archive.org/details/b30511902/page/282/mode/2up p.249 (3rd p.283-284) This distemper, barbarously in the Latin denominated scorbutus, is said to derive its appelation from schorbect in the Danish language ; or the old Dutch word scorbeck : both which signify a tearing or ulcers of the mouth. Most authors have deduced the term from the Saxon word schorbok, a griping or tearing of the belly ; which is by no means so usual a symptom of this disease ; though, from a mistake in the etymology of the name, it has been accounted so by these authors. The word seems to me most naturally to be made out from scorb in the Sclavonic language, which signifies a disease ; this being the endemic evil in Russia, and those northern countries, from whence we borrowed the name. p.252-253 (3rd p.287-289) That this disease was not known or described by Hippocrates, farther appears from his making no mention of spots, an usual symptom in the scurvy, nor of many others which almost constantly attend it. Upon the whole, we may be persuaded, that had this divine author seen the distemper, he, who studied nature with so much care, and copied her with so great exactness, would have left us a more accurate description of it. The succeeding Greek and Roman authors, are likewise upon this disease entirely silent… It also seems to have been a disease altogether unknown to the Arabian writers. p.256-257 (3rd p.293-294) For as there seem to have been two reasons principally why it is so imperfectly, if at all, described by the ancients, viz. their little knowledge of the northern countries, where it is peculiarly endemic, and their short coasting-voyages ; so we find, that as soon as arts and sciences began to be cultivated among those northern nations, (about the beginning of the sixteenth century, a period remarkable for the advancement of learning over all Europe), this disease is mentioned by their historians and other authors. We could not have expected it sooner from their physicians, if we reflect upon their extreme ignorance, and the little esteem this science was held in by them. In like manner, no sooner were long voyages performed to distant parts of the world, by the great improvement of navigation, and by the discovery of the Indies, which happened much about the same period of time, but the seamen were afflicted with it ; as appears by the voyage of Vasco de Gama, who first found out a passage by the Cape of Good Hope to the East Indies, in the year 1497 ; above a hundred of his men, out of the number of a hundred and sixty, dying in this distemper88. In the relation of which voyage, the first account of this disease at sea is to be met with. 88 Ravenstein EG (1898) A Journal of the First Voyage of Vasco da Gama, 1497-1499. https://www.gutenberg.org/ebooks/46440 https://www.gutenberg.org/files/46440/46440-h/46440-h.htm https://archive.org/details/ajournalfirstvo00ravegoog https://archive.org/details/ajournalfirstvo01ravegoog https://archive.org/details/ajournalfirstvo02ravegoog https://archive.org/details/ajournalofthefir46440gut https://archive.org/details/bub_gb_13stAAAAMAAJ https://archive.org/details/bub_gb_13stAAAAMAAJ_2 https://archive.org/details/dli.ministry.15443 https://archive.org/details/in.ernet.dli.2015.106906 https://archive.org/details/in.ernet.dli.2015.181606 https://archive.org/details/in.ernet.dli.2015.49451 https://archive.org/details/in.ernet.dli.2015.536306 https://archive.org/details/in.gov.ignca.21285 https://archive.org/details/journaloffirstvo0000unse 83 p.257-258 (3rd p.294-296) The second voyage of James Cartier to Newfoundland, by the grand bay up the river of Canada, ann. 1535.89 In the month of December, we understood that the pestilence was come upon the people of Stadacona ; and in such sort, that before we knew of it, above fifty of them died. Whereupon we charged them neither to come near our forts, nor about our ships. Notwithstanding which, the said unknown sickness began to spread itself amongst us, after the strangest sort that ever was either heard of or seen ; insomuch that some did lose all their strength, and could not stand upon their feet ; then did their legs swell, their sinews [tendon] shrunk, and became as black as a coal. Others had also their skin spotted with spots of blood, of a purple colour. It ascended up their ancles, knees, thighs, shoulders, arms and neck. Their mouth became stinking ; their gums so rotten, that all the flesh came away, even to the roots of their teeth ; which last did also almost all fall out. This infection spread so about the middle of February, that of a hundred and ten people, there were not ten whole ; so that one could not help the other ; a most horrible and pitiful case ! Eight were already dead ; and more than fifty sick, seemingly past all hopes of recovery. This malady being unknown to us, the body of one of our men was opened, to see if by any means possible the occasion of it might be discovered, and the rest of us preserved. But in such sort did the calamity increase, that there were not now above three sound men left. Twenty-five of our best men died ; and all the rest were so ill, that we thought they would never recover again : when it pleased God to cast his pitiful eye upon us, and send us the knowledge of a remedy for our health and recovery. Our Captain considering the deplorable condition of his people, one day went out of the fort, and walking upon the ice, he saw a troop of people coming from Stadacona. Among those was Domagaia, who not above ten or twelve days before laboured under this disease ; having his knees swelled as big as a child’s head of two years old, his sinews shrunk, his teeth spoiled, and his gums rotten and stinking. The Captain, upon seeing him now whole and sound, was thereat marvellous glad, hoping to know of him how he had cured himself. He acquainted him, that he had taken the juice of the leaves of a certain tree, a singular remedy in this disease. The tree in their language is called ameda or hanneda ; by a decoction of the bark and leaves of which, they were all perfectly recovered in a short time. Of the colony sent over from France, under the Lord of Roberval, there died in the winter fifty in this disease. 89 Baxter JP (1906) A memoir of Jacques Cartier, sieur de Limoilou, his voyages to the St. Lawrence, a bibliography and a facsimile of the manuscript of 1534. https://archive.org/details/memoirofjacquesc00baxt/page/190 See related documents: https://pubmed.ncbi.nlm.nih.gov/12422875 https://www.researchgate.net/publication/11043323 https://www.biusante.parisdescartes.fr/ishm/vesalius/VESx2002x08x01x002x006.pdf https://doi.org/10.3138/cbmh.7.2.161 https://doi.org/10.1001/jamadermatol.2014.4582 https://doi.org/10.1126/science.99.2563.125.a https://doi.org/10.1126/science.98.2545.325.a https://doi.org/10.1126/science.98.2541.242.a https://doi.org/10.1126/science.98.2541.241 https://doi.org/10.1126/science.98.2536.132.a https://doi.org/10.1126/science.97.2520.354.c https://doi.org/10.1126/science.92.2376.35.b 84 PART III: CHAPTER II Bibliotheca scorbutica : or, A chronological view of what has hitherto been published on the scurvy https://archive.org/details/b30511902/page/302/mode/2up [Lind reviews dozens of earlier reports of scurvy, but only those that report symptoms relevant for the current document are described here] Lind’s PREFACE: p.8-10 (3rd p.xii-xiv) The Bibliotheca scorbutica, or the collection of authors on the scurvy, is placed at the latter end of the book, as proper to be consulted in the dictionary-way… In the third part, where I have given an abridgment of what has been written upon the subject by the most celebrated medical authors, and others, I have always endeavoured to express their sentiments with as much clearness and conciseness as I could. I have indeed through the whole aimed at perspicuity rather than elegance of diction, as most proper in a book of science. To know a disease, and to cure it, being the two things most essential to be learned ; I have therefore transcribed the symptoms and cure of the scurvy from those authors, where they do not entirely copy from each other. Lind comments on the early publications in the beginning of his book as follows: p.11 (3rd p.1) In the first accounts given us of this disease, by Ronsseus, Echthius, and Wierus, it is surprising to find, not only an accurate description of it, but an enumeration of almost all the truly antiscorbutic medicines that are known to the world even at this day. The first authors on the scurvy, Ronsseus and Echthius, though cotemporary, wrote separately, without having the benefit of seeing each others works. Hirsch also considered that the first authors described scurvy properly: … the writings of Echthius, Ronsseus, Wier, Dodonaeus and Brucaeus, which testify to the comparatively common occurrence of the disease along the littoral of the North Sea and the Baltic… These excellent descriptions of the malady, more especially by Echthius, Ronsseus and Wier, leave no doubt as to its nature [as scurvy]. 85 p.262-348 (3rd ed 302-494) A.D. 1541 Joan. Echthii de scorbuto, vel scorbutica passione, epitome. “Ioannis Echthii De scorbuto, vel scorbutica passione epitome”, p.181-186. https://archive.org/details/descorbutotracta00senn https://www.google.fi/books/edition/De_scorbuto_tractatus/W7w_AAAAcAAJ https://www.google.fi/books/edition/De_scorbuto_tractatus_Acc_ejusdem_argume/f2RWAAAAcAAJ https://doi.org/10.31952/amha.16.2.2 He proposes it as a question, Whether the blood here may not be corrupted, without the spleen or any other of the viscera being affected ? but is inclined to think the spleen often is. He assigns as causes of this disease, gross unwholsome food, of salt, dried, or putrid flesh and fish, pork, spoiled bread, stinking water, &c. He distinguishes the symptoms into two classes. The first contains such as appear at the beginning, and are common to it with other diseases ; the second, the succeeding and more certain signs of the malady. Under the first, he comprehends a heaviness of the body, with a spontaneous lassitude, generally most sensibly felt after exercise ; a tightness of the breast, and a weakness of the legs ; an itching, redness, and pain of the gums ; a change of colour in the face to a darkish hue : and observes, that where all these concur, we may foretel an approaching scurvy. But the more immediate and certain signs he enumerates under the second class, viz. a fœtid breath, a spungy swelling of the gums, which are apt to bleed, with a loosening of the teeth ; an eruption of leaden-coloured, purple, or livid spots, on the legs ; or of somewhat broader speckled or darkcoloured maculæ, sometimes on the face, at other times on the legs. As the disease advances, the patients lose the use of their legs, and are subject to a difficulty of breathing, particularly when moved, or when they sit erect ; at which times they are apt to faint : but upon being laid down again, they recover, and breathe freely ; nay, when lying, they affirm that nothing ails them. But as they cannot always thus continue without some motion, they are subject to these perpetual swoons90. The appetite is seldom bad ; on the contrary, they generally have a good one. There is sometimes observed an aggravation of the symptoms ; with some on the fourth or fifth day, in others on the third. Some few have it every day, but without any fever : others become feverish. Preceeding fevers may terminate critically, as it were, in the scurvy : and with such scurvies whole families and monasteries are together infected ; which generally end either in a deadly dysentery, or, at other times, in a sudden and mortal faint. During the course of this disease, some are apt to be very costive ; while others have a continual diarrhœa. Sometimes their spotted legs swell so monstrously, as to resemble the elephantiasis of the Arabians ; while others have them so extenuated, that the bones seem only covered with skin. The spots of some separate into black and duskish scales, like the morphæa and leprosy of the Greeks ; while in others they remain soft, smooth, and shining ; and the impression of the finger continues for some time upon the part. In those who die, the spots sometimes disappear ; at other times they break out afresh. Lastly, there have been observed varicose swellings of the veins, as in those under the tongue, and of the lower lip. He afterwards delivers the indications of cure, without giving us any remedies. And it may not be amiss to remark, that this is the first description now extant of the scurvy by a physician. 90 Faint 86 1564 Balduini Ronssei de Magnis Hippocratis lienibus, Pliniique stomacase ac sceletyrbe, seu vulgo dicto scorbuto commentarius. Ejusdem epistolæ quinque ejusdem argumenti. “Balduini Ronssei Gandensis De Magnis Hippocratis Lienibus, Pliniique stomacase ac sceletyrbe, seu vulgò dicto scorbuto commentarius. Ejusdem epistolae quinque, eisdem argumenti”, p.139-180. https://archive.org/details/descorbutotracta00senn https://www.google.fi/books/edition/De_scorbuto_tractatus/W7w_AAAAcAAJ https://www.google.fi/books/edition/De_scorbuto_tractatus_Acc_ejusdem_argume/f2RWAAAAcAAJ https://archive.org/details/hin-wel-all-00002888-001 [Although Lind states that Ronsseus properly describes the symptoms of scurvy, in a similar way as Echthius (p.11 and 3rd p.1), Lind does not extract the symptoms that Ronsseus had described. Lind mentions oranges as treatment as follows: Ronsseus had stated that “seamen in long voyages cure themselves of it by the use of oranges”] 1567 Jo. Wieri medicarum observationum hactenus incognitarum lib. I. de scorbuto. https://archive.org/details/bub_gb_-FqKIF7hHB4C “Ioannis Wieri. De scorbuto tractatus”, p.187-205. https://archive.org/details/descorbutotracta00senn https://www.google.fi/books/edition/De_scorbuto_tractatus/W7w_AAAAcAAJ https://www.google.fi/books/edition/De_scorbuto_tractatus_Acc_ejusdem_argume/f2RWAAAAcAAJ He transcribes all the symptoms out of Echthius at great length, with the following additions. The weakness in the legs felt upon the approach of the disease, is attended with a stiffness there, and a small pain. The flesh of the gums is often destroyed to the roots of the teeth. Smaller spots, resembling blood sprinkled upon the part, (or flea-bites, but larger), appear on the legs, thighs, and on the whole body ; but the very large, livid, and purple spots, chiefly on the legs. Sometimes this livid colour will shew itself in the fauces of those who are near death. In the progress of the disease, the tendons of the legs become stiff and contracted. Some are seized with a slow erratic fever. After ardent malignant fevers, and double tertians, ill cured, he has known the scurvy to follow ; upon which a malignant quartan has ensued. This still left the scurvy behind it ; which was at last cured by the proper method. When the legs are greatly swelled, they are sometimes altogether of a livid colour. The pulse, as in a quartan fever, varies : so that at different times, and according to the state of the disease, it is small, hard, quick, and weak. The urine is reddish, turbid, thick, and fæculent, like new red wine, resembling that which is usual in the fit of a quartan when sweating ; and of a bad smell… 1589 De scorbuto propositiones de quibus disputatum est publice Rostochii, sub Henrico Brucæo. The scurvy is endemic in particular countries, from their situation, air, water, and food. In these countries, scorbutic mothers bear scorbutic children, often miscarry, at other times bring forth dead fœtuses. He mentions no other symptom, but what is taken notice of by Wierus ; except a pain 87 sometimes in the right, at other times in the left hypochondrium, attended with a sense of weight. Upon the malady’s increasing, the belly swells, and grows also painful ; with an entire loss of appetite. In his theory of the disease, he supposes, that either the liver, or spleen, sometimes both, but oftener the spleen, was obstructed ; although it was seldom found scirrhous91. He afterwards says, there is often no swelling or obstruction in any of these parts ; though, from the quality of the scorbutic humour, produced by improper and gross food, it was natural to expect the spleen might be affected. When the disease is very inveterate, it degenerates into the affectio hypochondriaca ; a distemper frequent among the inhabitants on the shores of the Baltic. It is sometimes complicated with other diseases, viz. the dropsy, atrophy, and bilious diarrhœa ; at other times there is a slow continual fever, and sometimes a tertian intermittent. His cure consists… If the patient is of a cold habit, has œdematous legs… 1593 Scorbuti historia proposita in publicum; a Solomone Alberto, &c. "Schorbuti historia proposita in publicum. A Salomone Alberto Norinbergensi, Medic. D. & in Acad. Wittebergensi Profess. primatio", p.211-296 https://archive.org/details/descorbutotracta00senn https://www.google.fi/books/edition/De_scorbuto_tractatus/W7w_AAAAcAAJ https://www.google.fi/books/edition/De_scorbuto_tractatus_Acc_ejusdem_argume/f2RWAAAAcAAJ … by giving diuretics if it tends to the kidneys ; having particularly remarked, that, by a flow of urine, the disorders of the breast in this disease were most effectually relieved… [See section Strengths and limitations of the descriptions of symptoms of scurvy by early authors] 1595 Petri Foresti observationum et curationum medicinalium lib. 20. obs. 11. de scorbuto malo cognoscendo et curando ; obs. 12. ibid, de quinque ægris a scorbuto curatis. The patient was troubled with a great difficulty of breathing, had lost the use of his limbs ; his left knee, and whole leg, being swelled, scirrhous, spotted, and so stiff, that he could not walk, or even move himself… Forestus, who has had great practice in this disease, says, the pathognomonic signs of it are, a straitness of the præcordia ; weakness and pain of the legs ; redness, pain, and itching in the gums ; with an alteration of colour in the face. However, in the beginning it is not so easily known ; being sometimes slow in its progress, and having the above symptoms, together with a lassitude after exercise, common to it with other diseases. But where all such signs appear together, he thinks it the beginning of the distemper, or at least there is some certainty of an approaching scurvy… In particular, after the remarkable proneness to swoon in the height of the malady, he adds, that he has known several drop down dead instantly… 91 A hard slow-growing malignant tumor having a preponderance of fibrous tissue 88 1600 Hieronymi Reusneri diexodicarum exercitationum liber de scorbuto. https://books.google.fi/books/about/Hieronymi_Reusneri_Diexodicarum_exercita.html?id=D0VNmgEACAAJ A hæmorrhage from the nose, which he says is usual even in the beginning of the disease ; as likewise a continual spitting. Some have a pain at the mouth of the stomach, and there is a want of appetite ; or at least if they long for food, it is rather hurtful to them. He observes, that scorbutical women are subject to the fluor albus, and menses discolores. The urine is for the most part thin, pale, and watery, without any sediment, and of a fœtid smell. The pulse is low, weak, slow, and inordinate. 1604 De morbo scorbuto liber; cum observationibus quibusdam, brevique et succincta cujusque curationis indicatione. Auctore Severino Eugaleno. https://archive.org/details/b33007676 https://archive.org/details/b32991368_0001 https://archive.org/details/DeScorbutoLiberCumObservationibusQuibusdam Eugalenus does mention “a difficulty of breathing”, ”uneasy straitness and oppression upon the præcordia”,”disorders of the breast, cough, pain, orthopnœa”, “dropsy”. However, not much weight can be put on the descriptions of Eugalenus, as he listed 49 different scurvy symptoms. See severe criticism in the section Strengths and limitations of the descriptions of symptoms of scurvy by early authors 1608 Felicis Plateri praxeos medica lib. 3. cap. 4. de defadatione. Under which title, he treats of the lues venerea, scorbutica, and elephantica. The sweat of scorbutic persons is fœtid ; their urine red and turbid ; their pulse feeble … may end in… dropsy 1608 [in the 3rd ed, not in the 1st ed] Relazao do Viage de Don Sebastian Vizcaino, &c. or the Voyage of Don Sebastian Vizcaino, performed in the year 1602, to the western coast of California, with two large ships and a frigate. https://en.wikipedia.org/wiki/Sebasti%C3%A1n_Vizca%C3%ADno It will not be foreign to the purpose, to mention here the sickness which raged among the squadron, being the same, which in these parts generally seizes on those who are coming from China to New Spain, and which proves so fatal as to sweep off half the ship’s company. In this latitude the air is very sharp and cold, which pierces those of weak constitutions, and perhaps of a pestilential nature ; unless we suppose that its great subtility is sufficient to cause such a disease in bodies attenuated by fatigues. Its first symptom is an universal pain all over the body; which now becomes to tender, as not to bear the least touch ; and sometimes this will extort tears and cries from the most resolute men. After 89 [In Part I, Chapter I, Lind criticizes Thomas Willis, and p.153: “Legions of distempers (according to Willis and others) very different from the real and genuine scurvy, have been classed under its name”] He observes, that no single description or definition of this distemper can be given ; and, consequently, that the best method of describing it, is according to the different parts affected of the body ; in all which it produces manifold symptoms. The breast is affected with pains in different parts of its membranes, chiefly on the sternum, where they are very violent, acute, and darting ; frequent asthma’s ; difficult and unequal respiration ; straitness of the breast ; violent cough ; inordinate pulse ; palpitation of the heart ; frequent faintings, and the continual dread of them. … cardialgia… In the limbs, or even over the whole body, there are wandering pains, often very acute, and becoming worse at night ; a spontaneous lassitude ; wasting of the flesh ; lumbago, a weakness of the other joints ; spots of various colours on the skin ; tumours, tubercles, and often cacoethic ulcers ; a stupor or stinging pain about the muscles ; a sense of cold as it were in the parts ; contractions and subsultus of the tendons. Besides these, scorbutic people are subject to irregular effervescencies of the blood, erratic fevers, and profuse hæmorrhages. He concludes this long detail with observing, that these are the most common and usual symptoms of the scurvy, sometimes more, sometimes fewer, of this or that kind, afflicting the diseased : but besides what have been already mentioned, there occur in it more uncommon and prodigious appearances. 1672 De scorbuto liber singularis ; auctore Gualtero Charleton. https://archive.org/details/bub_gb_Cp7E8Ui3Vs4C … cardialgia… … the symptoms are, straitness of the breast, palpitation of the heart, and faintings ; numbness and lassitude of the body… … palpitations of the heart ; a sudden stoppage of the pulse, attended with great anxiety, ending in a faint, with a cold sweat. 1675 The disease of London ; or, A new discovery of the scurvy. By Gideon Harvey. https://wellcomecollection.org/works/ee8fvrhh https://name.umdl.umich.edu/A43016.0001.001 Biography: https://en.wikipedia.org/wiki/Gideon_Harvey https://history.rcplondon.ac.uk/inspiring-physicians/gideon-harvey … swelling and ulcers of the legs… 96 1683 [in the 3rd ed, not in the 1st ed] Une voyage aux Indes orientales, ecrit par M. Dellon, M. D. Supplement, chap. 2. Of the scurvy, called by the French the land evil. This is the most dangerous and troublesome of all the distempers incident in a long voyage, being contagious, and scarce ever to be cured at sea. The symptoms first appear in the mouth and gums, which swell, grow black, and emit a disagreeable scent. Deep incisions are requisite in order to remove a considerable quantity of corrupted flesh and matter, which not only loosens the teeth, but makes them fall out, The next symptoms that appear are certain black spots on the arms, legs, and thighs, and then over the body. The broader these spots are, and the nearer the heart, the more dangerous is the distemper. The corruption in the gums, and blotches over the body, are followed by a nausea, laziness, fainting fits, pains in the head, arms, and legs, and last of all with a looseness. There is seldom any fever ; the pulse in this malady declining very little from its natural state. For prevention… Each person on board ought to provide himself with juice of citrons, lemons, ros folis, and dried fruits, especially prunes, and not to abstain long from drinking. 1685 Thomæ Sydenham opera universa. Biography: https://en.wikipedia.org/wiki/Thomas_Sydenham https://history.rcplondon.ac.uk/inspiring-physicians/thomas-sydenham https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1074042 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1073363 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1707886 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1293116 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2305323 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3199640 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7939282 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7945918 The author has no where treated expressly of this disease, but in a posthumous work ascribed to him… … scurvy is said to be accompanied with, 1. spontaneous lassitude ; 2. heaviness ; 3. difficulty of breathing, especially after exercise ; 4. rottenness of the gums ; 5. fœtid breath ; 6. frequent bleeding at the nose ; 7. difficulty of walking ; 8. a swelling sometimes, at other times a wasting of the legs ; on which spots always appear, that are either livid, or of a leaden, yellow, or purple colour ; 9. a sallow complexion. … dropsy… 97 1696 Archibaldi Pitcarnii element. medicinæ physico-mathematic. lib. 2. cap. 23. de scorbuto. https://archive.org/details/ElementaMedicinaePhysicoMathematicaLibriDuobus/page/n250/mode/1up https://archive.org/details/bim_eighteenth-century_elementa-medicinae-phys_pitcairne-archibald_1717/page/n300 The symptoms of the scurvy are said to be, a redness, itching, putrefaction, and bleeding of the gums; loose teeth ; spots on the legs, first red, then livid, and blackish ; an unusual lassitude; a red sandy sediment in the urine, so that it appears lixivial93 ; an unequal pulse , wandering pains… … faintings, fluxes, or a difficulty of breathing, afflict the patient… 1708 Hermanni Boerhaave aphorismi de cognoscendis et curandis morbis. Aph. 1148. &c. de scorbuto. https://archive.org/details/b30532188_0002/page/240 https://archive.org/details/b30771109_0002/page/298 https://archive.org/details/b33023773/page/302 https://archive.org/details/bub_gb_8OrYEXf7vzAC/page/n319 https://archive.org/details/bim_eighteenth-century_aphorismi-de-cognoscendi_boerhaave-herman-1668-_1744/page/262 Biography: https://en.wikipedia.org/wiki/Herman_Boerhaave https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1009928 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1033870 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1296534 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1912963 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5270803 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc547936 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7932630 Sect. 1. An unusual laziness ; an inclination to rest ; a spontaneous lassitude ; a general heaviness ; pain of all the muscles as after too great a fatigue, particularly in the legs and loins ; an extreme difficulty in walking, especially up or down a steep place ; in the morning, upon awaking, the limbs and muscles feel as if wearied and bruised. Sect. 2. A difficulty of breathing, panting, and almost suffocation, upon every little motion ; a swelling of the legs, often disappearing, and an inability to move them, from their weight… Sect. 4. …diarrhœa; dysenteries; severe stranguries ; faintings ; and an oppression upon the præcordia, often suddenly mortal ; a dropsy… 1732, 1734 An account of the scurvy at Wiburg. Communicated by Dr Abraham Nitzsch to Dr Schulze. Commerc. literar. Norimb. ann. 1734, p. 162. I observed the appearances of the disease were not the same in all ; but different in individuals… Those who were of a lax habit, laboured under an œdematous swelling of the legs, (rarely of the abdomen), yielding easily to the impression of the finger, but often becoming harder upon the continuance of the malady. The hypochondria for the most part were tumid94, the flexor tendons of the tibia always contracted, with livid spots on the legs, knees, thighs, and back. These in plethoric 93 Alcaline 94 Swollen 98 habits, particularly upon the tibia, became often inflamed, attended with most acute pain, and quickness of the pulse. Now and then the white of the eye was altogether bloody ; and sometimes the eye-lids were greatly swelled, being distended with extravasated, stagnating blood. In some the spots were pretty large, especially upon the thighs and back ; in others they resembled only flea bites, and were accompanied with swelling of the legs, universal lassitude, swelled, bleeding, and putrid gums; as also a pale wan countenance. Several were distressed with a great difficulty of breathing, moist cough, a vertigo, and faintings, most commonly when in an erect posture ; the latter often proved fatal to those who had been long afflicted… The anguish did not fix in one place, but by shifting produced arthritic pains, colics, the spasmodic asthma, headachs, toothachs, and contractions… … calf of the leg and scrotum, when there appeared a tense watery swelling upon these parts… 1734 Parerga medica conscripta a Damiano Sinopeo. https://wellcomecollection.org/works/y9ycvngm In Cronstadt … the scurvy is an endemic and common disease. The symptoms are, a putrid swelling of the gums, lassitude, and a remarkable pain and weakness of the legs ; swelling of the feet and knees ; contraction of the tendons ; a cachectic, and, as it were, anasarcous habit of body, with a dark yellowish hue ; costiveness, and a thick lateritious95 urine. After those appearances, ensue pain, and even contractions of the upper extremities ; livid spots of different sizes ; pains in the shoulders, and small of the back. These latter prove very violent in such as are tainted with the venereal poison. Few die of this distemper ; for the most part only those who have become consumptive or dropsical. In the months of April and May it raged with uncommon violence, and continued almost till the middle of July ; when it was abated by the heat of the season. Some patients became anasarcous, or dropsical ; others phthisical96. Some laboured under the most violent colics, with obstinate contraction of the belly ; others were seized with a sphacelus 97 of the gums and fauces, scorbutic tumours, &c. Soft livid swellings arose upon the body : they were judged to be full of matter; but, upon opening them, nothing was discharged but a blackish dissolved blood : the ulcer was surrounded by : fungous rotten flesh, whose basis seemed very deep, and bled upon the gentlest touch. Although the scurvy was a distemper bad enough of itself, it was, however, often rendered worse by being complicated with other intercurrent diseases, viz. fevers, and rheumatisms, but especially the intermitting fever. All who recovered from this last, became scorbutic. There was scarce any person, either in the hospital or town, who laboured under even a chronic disease, who was not more or less affected by the scurvy. Hence all diseases whatever became more troublesome and obstinate this spring. The scurvy having entirely ceased in July, a few mild fevers took place the rest of the summer, and autumn. 95 Bright red 96 A progressively wasting or consumptive condition (~tuberculosis) 97 Gangrene 99 1737, 1720 Jo. Geo. Henrici Krameri dissertatio epistolica de scorbuto. The case of the Imperial troops in Hungary; transmitted to the college of physicians at Vienna, by the author. https://books.google.fi/books?id=DgteAAAAcAAJ https://books.google.fi/books?id=mnd0vwEACAAJ The muscles of the legs, thighs, and even cheeks, become greatly swelled, and hard, nay, altogether indurated. But those swellings, as also the large ecchymoses, never suppurate. The pulse is quick, small, and hard… The difficulty of breathing is so great, that the patients not only faint away upon the slightest motion of the body ; but frequently, when walking about, drop down suddenly dead. They generally complain excessively of this dyspnœa, a few days before death, though they have neither cough nor spitting. All the species of dropsies, and œdematous swellings on the body, accompany the advanced stages of this calamity ; in so much that, by lying with the head in a declining posture, the face in half an hour becomes so swelled, that the person cannot open his eyes. Such swellings often disappear and return. … Orthopnœa, dropsy, and dysentery, attending the last stage, render the case often incurable… In many thousand scorbutic patients… Scorbutic people… Their death is for the most part tranquil, if you except their laborious breathing. 1739 Frederici Hoffmanni medicinæ rationalis systematicæ tom 4. part 5. cap. 1. de scorbuto, ejusque vera indole. … After a preceding scorbutic dyspnœa, the patient is very apt to fall into a dropsy… 1747 Theoretisch practische abhandlung des scharboctes, wie sich derselbige vornemlich bey denen kayserlich Ruszischen armeen an verschiedenen orten geaussert and gezeiget hat, &c.: or, A theoretical and practical treatise of the scurvy, as it has appeared chiefly in the Imperial Russian armies, together with a circumstantial description of its causes, means of prevention, and cure. By Abraham Nitzsch. https://play.google.com/store/books/details/Abraham_Nitzsch_Theoretisch_practische_Abhandlung?id=szFh66Kk64kC There is a general lassitude. The thighs and legs feel heavy ; and a remarkable weakness is perceived in the knees. At the same time the gums begin to swell and corrupt. The preternatural colour of the face afterwards increases, the legs begin to be painful, the cheeks and bones swell, the gums become monstrously rotten, the body more feeble, and a difficulty of breathing ensues upon using of exercise. The knees and joints are also contracted. Finally, the appetite gradually decays, the body becomes constipated… … the quickness of the pulse, being always increased… 100 … an universal pale swelling covers the body ; which becomes of a yellowish colour… the thighs and arms are prodigiously swelled and indurated… an anasarca is induced ; when within the substance of the lungs, an asthma, upon which a true hydrops pectoris ensues ; when in the lower belly, an ascites per infiltrationem… It also produces a spasmodic suffocative asthma. These are the chief kinds of the slow scurvy, which occurred in the Russian armies, and fell under the author’s observation. The principal reason why… such a considerable number were attacked by the scurvy, and brought into the hospital… was, the excessive fatigues they underwent through the whole winter… 1748 https://archive.org/details/b30511902/page/440/mode/2up A voyage round the world, in the years 1740, 41, 42, 43, 44, by George Anson, Esq. ; now Lord Anson, commander in chief of a squadron of his Majesty’s ships, sent upon an expedition to the South seas. Compiled from his papers and materials, by Richard Walter, M.A. &c. https://www.gutenberg.org/ebooks/16611 https://www.gutenberg.org/files/16611/16611-h/16611-h.htm https://archive.org/details/voyageroundworld00walt https://archive.org/details/voyageroundworld00walt_0 https://archive.org/details/voyageroundworld00walt_1 https://archive.org/details/voyageroundworld00walt_2 https://archive.org/details/voyageroundworld00waltuoft https://archive.org/details/gri_33125011256381 https://archive.org/details/in.ernet.dli.2015.42984 https://archive.org/details/cihm_17410 https://archive.org/details/cihm_18288 https://archive.org/details/cihm_27757 https://archive.org/details/cihm_27900 https://archive.org/details/cihm_32030 https://archive.org/details/cihm_32032 https://archive.org/details/cu31924023252152 https://archive.org/details/voyageautourdum00waltgoog (French) https://archive.org/details/cihm_17436 (French) https://archive.org/details/bub_gb_GGNYAAAAcAAJ (German) https://archive.org/details/desherrnadmirals00walt (German) https://archive.org/details/reizerondsomdewe00walt (Dutch) Related sources: https://doi.org/10.2307/1784959 https://doi.org/10.2307/1796436 https://doi.org/10.2307/1851436 https://doi.org/10.2307/2510937 https://doi.org/10.2307/4053467 https://doi.org/10.1086/ahr/73.5.1525 https://doi.org/10.1177/084387140001200278 https://doi.org/10.25290/prinunivlibrchro.64.2.0289 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc9662994 https://archive.org/details/prizeofalloceans0000will_o5i8 https://www.publishersweekly.com/9780670891979 https://en.wikipedia.org/wiki/George_Anson%27s_voyage_around_the_world 101 https://www.historyireland.com/an-island-of-cosmopolitan-culture-ansons-voyage-round-the-world-and-thelibrary-at-bowens-court-co-cork [Anson’s voyage is such interesting that this section from Lind is copied in full, the book-length texts are available through the links above] Soon after our passing straits Le Maire, the scurvy began to make its appearance amongst us : and our long continuance at sea, the fatigue we underwent, and the various disappointments we met with, had occasioned its spreading to such a degree, that, at the latter end of April, there were but few on board who were not in some degree afflicted with it ; and in that month no less than fortythree died of it on board the Centurion. But tho’ we thought, that the distemper had then risen to an extraordinary height ; and were willing to hope, that as we advanced to the northward, its malignity would abate : yet we found, on the contrary, that, in the month of May, we lost near double that number. And as we did not get to land till the middle of June, the mortality went on increasing ; so that, after the loss of above 200 men, we could not at last muster more than six foremast men in a watch, capable of duty. This disease, so frequently attending all long voyages, and so particularly destructive to us, is surely the most singular and unaccountable of any that affects the human body. Its symptoms are unconstant and innumerable, and its progress and effects extremely irregular : for scarcely any two persons have the same complaints ; and where there hath been found some conformity in the symptoms, the order of their appearance has been totally different. However, though it frequently puts on the form of many other diseases, and is therefore not to be described by any exclusive and infallible criterions ; yet there are some symptoms which are more general than the rest, and occurring the oftenest, deserve a more particular enumeration. These common appearances are, large discoloured spots dispersed over the whole surface of the body ; swelled legs ; putrid gums ; and, above all, an extraordinary lassitude of the whole body, especially after any exercise, however inconsiderable : and this lassitude at last degenerates into a proneness to swoon, on the least exertion of strength, or even on the least motion. This disease is likewise usually attended with a strange dejection of spirits ; and with shiverings, tremblings, and a disposition to be seized with the most dreadful terrors, on the slightest accident. Indeed it was most remarkable, in all our reiterated experience of this malady, that whatever discouraged our people, or at any time damped their hopes, never failed to add new vigour to the distemper : for it usually killed those who were in the last stages of it, and confined those to their hammocks who were before capable of some kind of duty. So that it seemed, as if alacrity of mind, and sanguine thoughts, were no contemptible preservatives from its fatal malignity. But it is not easy to complete the long roll of the various concomitants of this disease. For it often produced putrid fevers, pleurisies, the jaundice, and violent rheumatic pains. And sometimes it occasioned an obstinate costiveness ; which was generally attended with a difficulty of breathing ; and this was esteemed the most deadly of all the scorbutic symptoms. At other times the whole body, but more especially the legs, were subject to ulcers of the worst kind, attended with rotten bones, and such a luxuriancy of fungous flesh as yielded to no remedy. But a most extraordinary circumstance, and what would be scarcely credible upon any single evidence, is, that the scars of wounds which had been for many years healed, were forced open again by this virulent distemper. Of this there was a remarkable instance in one of the invalids on board the Centurion, who had been wounded above fifty years before at the battle of the Boyne : for though he was cured soon after, 102 and had continued well for a great number of years past ; yet, on his being attacked by the scurvy, his wounds, in the progress of his disease, broke out afresh, and appeared as if they had never been healed. Nay, what is still more astonishing, the callous of a broken bone, which had been compleatly formed for a long time, was found to be hereby dissolved ; and the fracture seemed as if it had never been consolidated. Indeed, the effects of this disease were in almost every instance wonderful. For many of our people, though confined to their hammocks, appeared to have no inconsiderable share of health ; for they eat and drank heartily, were chearful, and talked with much seeming vigour, and with a loud strong tone of voice ; and yet on their being the least moved, tho’ it was only from one part of the ship to the other, and that in their hammocks, they have immediately expired. And others, who have confided in their seeming strength, and have resolved to get out of their hammocks, have died before they could well reach the deck. And it was no uncommon thing for those who could do some kind of duty, and walk the deck, to drop down dead in an instant, on any endeavours to act with their utmost vigour ; many of our people having perished in this manner, during the course of this voyage. Upon arriving at the island of Juan Fernandes, 167 sick persons were put on shore, besides at least a dozen who died in the boats, on their being exposed to the fresh air. The extreme weakness of the sick may be collected from the numbers who died after they got on shore : for it had generally been found, that the land, and the refreshments it produces, very soon recover most stages of the seascurvy ; yet it was near twenty days after their landing, before the mortality was tolerably ceased : and for the first ten or twelve days, they buried rarely less than six each day ; and many of those who survived, recovered by very slow and insensible degrees. Indeed those who were well enough, at their first getting on shore, to creep out of their tents, and crawl about, were soon relieved, and recovered their health and strength in a very short time ; but in the rest, the disease seemed to have acquired a degree of inveteracy altogether without example. It was very remarkable what happened to the Gloucester, which, like the other ships in that squadron, had suffered the most unparallelled hardships, and buried three fourths of her crew in this disease ; that, upon landing the remainder of her sick, less than eighty in number, very few of them died. Whether it was, (as the ingenious author observes), that the farthest advanced in the distemper were already dead, or the greens and fresh provisions sent on board them when plying off that island, had prepared those who remained for a speedy recovery ; their sick, however, in general, got much sooner well than the Centurion’ s crew. The havock which this dreadful calamity made in those ships, was truly surprising. The Centurion, from her leaving England, when at this island, had buried 292 men, and had but 214 remaining of her complement. The Gloucester, out of a smaller complement, buried the same number, and had only 82 alive. This dreadful mortality had fallen severer on the invalids and marines than on the sailors : for on board the Centurion, out of fifty invalids, and seventy-nine marines, there remained only four invalids, including officers, and eleven marines ; and on board the Gloucester, every invalid died, and only two marines escaped out of forty-eight. In less, however, than seven weeks after leaving the coast of Mexico, having continued in perfect health for a considerable time before, this fatal disease broke out again amongst them. Upon which occasion, the ingenious author makes the following remarks. Some amongst us were willing to believe, that in this warm climate the violence of the disease, and its fatality, might be in some degree mitigated. But the ravage of the distemper at that time 103 convinced them of the falsity of this speculation ; as it likewise exploded other opinions about the cause and nature of this disease. For it has been generally presumed, that plenty of water, and of fresh provisions, are effectual preventives of this malady. But it happened in the present case, we had a considerable stock of fresh provisions on board, being the hogs and fowls taken at Paita. We besides, almost daily, caught abundance of bonito’s, dolphins, and albicores : and the unsettled season having proved extremely rainy, supplied us with plenty of water ; so that each man had five pints plenty of water, and fresh provisions distributed among the sick, and the whole crew often fed upon fish ; yet neither were the sick hereby relieved, nor the progress and advancement of the disease retarded. It has likewise been believed by many, that keeping the ship clean and airy betwixt decks, might prevent, or at least mitigate the scurvy ; yet we observed, during the latter part of our run, that, though we kept all our ports open, and took uncommon pains in sweetening and cleansing the ships ; yet neither the progress, nor the virulence of the disease were thereby sensibly abated. The surgeon at this time having declared, that all his measures were totally ineffectual for the relief of his patients, it was resolved to try the effects of Ward’s drop and pill ; and one, or both of them, at different times, were given to persons in every stage of the distemper. Out of the number who took them, one, soon after swallowing the pill, was seized with a violent bleeding at the nose. He was before given over by the surgeon, and lay almost at the point of death ; but he immediately found himself much better, and continued to recover, though slowly, till we arrived on shore near a fortnight after. A few others were relieved for some days. But the disease returned again with as much virulence as ever ; though neither did these, nor the rest who received no benefit, appear to be reduced to a worse condition than they would have been if they had taken nothing. The most remarkable property of these medicines in almost every one that took them, was, that they operated in proportion to the vigour of the patient. So that those who were within two or three days of dying, were scarcely affected ; and as the patient was differently advanced in the disease, the operation was either a gentle perspiration, an easy vomit, or a moderate purge. But if they were taken by one in full strength, they then produced all the before mentioned effects with considerable violence ; which sometimes continued for six or eight hours together with little intermission. Upon their arrival at Tinian, they soon began to feel the salutary influence of the land : for though they had buried in two days before twenty-one men, yet they did not lose above ten more from the day after they were landed ; and reaped so much benefit from the fruits of the island, particularly those of the acid kind, that in a week’s time there were but few of them who were not so far recovered as to be able to move about without help. 104 1748 A voyage to Hudson’s-bay, by the Dobbs galley, and California, in the years 1746 and 1747, for discovering a north-west passage. By Henry Ellis https://archive.org/details/voyagetohudsonsb00elli https://archive.org/details/voyagetohudsonsb00inelli https://archive.org/details/voyagetohudsonsb0000elli https://archive.org/details/voyagetohudsonsb0000henr https://archive.org/details/cihm_34894 https://archive.org/details/cihm_34895 https://archive.org/details/voyagedelabayed00elligoog (French) https://archive.org/details/cihm_34805 (French) https://archive.org/details/cihm_37565 (French) https://archive.org/details/cihm_90268 (French) https://archive.org/details/reisenachhudsons00elli (German) https://archive.org/details/cihm_16680 (German) https://archive.org/details/cihm_35218 (Dutch) https://en.wikipedia.org/wiki/Henry_Ellis_(governor) Our men, when first seized with it, began to droop, to grow heavy, listless, and at length indolent, to the last degree : a tightness in the chest, pains in the breast, and a great difficulty in breathing followed ; then ensued livid spots upon the thighs, swelled legs, contraction of the limbs, putrid gums, teeth loose, a coagulation of blood upon and near the back-bone, with countenances bloated and sallow ; these symptoms continually increasing, till at length death carried them off, either by a flux or a dropsy. 105 But it must be remembered, as I said before, that a dropsical disposition does not always accompany this disease. In some cases the legs do not swell at all, but continue, through the whole course of the disease, hard, painful, and discoloured ; when there is no water, and but little blood effused in them, they are for the most part greatly emaciated. (p.502) The acute pain in the breast, so frequent in this disease, is most commonly felt on the left side, about an hand-breadth above the pit of the stomach, at the articulation of the ribs with the breastbone. I have often observed, at that place, swellings of the cartilages. Sudden death is often occasioned by the rupture of a blood vessel, and a subsequent discharge of the blood into one of the large cavities of the body. I have remarked this to happen in the breast ; and once observed coagulated blood swimming in the liquor of the pericardium, or membrane inverting the heart, however it most frequently occurs in the belly… In patients, whose deaths were unexpected and sudden, and where no effusion of blood could be perceived in any cavity of the body ; the heart was commonly much distended with blood : the auricles and ventricles of both sides were filled, but those on the right to the greatest degree. (p.503) In one man, who suddenly dropped down dead, while walking in the fields ; there was a large polypus99 which filled entirely the right ventricle of the heart, and sent forth two branches, one into the pulmonary artery, another through the right auricle into the vena cava. But I am apt to think those polypous appearances, so commonly found in the heart of those who die of the scurvy, are formed after death. And, indeed, it is impossible to conceive, that the branch of a polypus should run in a living person from the heart into the vena cava, it being contrary to the well known course of the circulation of the blood. In the same person, a few clots of blood were found in the cavity of the breast. The doctrine of polypous concretions in the heart, during life, is upon the whole very exceptionable, and the fatal consequences said to arise from thence are often merely imaginary. That these concretions are most probably formed after death, appears from their being generally found in the right ventricle, seldom in the left ventricle of the heart, the former of which after death is generally distended with blood, the latter seldom contains any. [In scurvy the right heart is often enlarged. That may be caused by increased pulmonary resistance. Thus, it is possible that the slowed blood flow through the right heart leads to the formation of a thrombus in the right heart. Therefore Lind’s assumption that thrombus is formed after death is not necessarily correct.] 99 Polypus: Cardiac thrombus usually found post-mortem. “The term ‘Polypus cordis’ was first used by the audience of leading physicians of Amsterdam, at an autopsy by Nicolaas Tulp”. https://doi.org/10.1017/s0025727300060385 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1037031 https://doi.org/10.1017/s0025727300068393 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1044424 112 POSTRIPT to the 3rd ed. (1772) SECTION II: Effects of the scurvy on other diseases. https://archive.org/details/b30511902/page/504/mode/2up (p.504-505) I have remarked among some thousand patients in Haslar hospital, that such as were scorbutic, were not liable to be seized with fevers and that even an infection from a fever was long resisted by a scorbutic habit of body. To illustrate this remark, I must observe, that patients in an advanced state of the scurvy have often a quick and low pulse, and at times a considerable degree of heat on the skin… … Much about this period of the disorder, it is usual for a few to be suddenly attacked with the scorbutic pain in the breast, a difficulty of breathing, and cough. This I conjectured might be owing to the water being suddenly, and in too great a quantity removed from the cellular membrane of the legs, into the cavity of the chest. I have examined the cases of several thousand scorbutic patients, who had been sent from different ships, in order to find, whether any other fever was commonly attendant on the scurvy, than what has been already mentioned. SECTION III: State of the blood and secretions in the scurvy. (p.515) Now, in several scorbutic habits, there is a manifest redundancy of water, stagnating in the body ; by reason not only of the weakness of the solids, or of the constitution, but also from a diminution of the watery secretions. 113 POSTRIPT to the 3rd ed. (1772) SECTION V: The cure. https://archive.org/details/b30511902/page/520/mode/2up (p.521) But what I have found highly to improve the antiscorbutic virtues of the juice, was an addition of wine and sugar… such draughts ought always to be administered : they frequently prove greatly diuretic, and will sometimes occasion profuse sweats. (p.523-526) George Young, ten days after a fever, was seized with the scurvy in his legs. They became extremely painful and swelled towards the evening… He was extremely weak, had a cough… he eat two apples every day, and had broth with greens for three weeks, mending but slowly till ordered fresh lemons, then he recovered apace. Reeves was long ill of a fever and flux, by which he was greatly reduced. He complained of intolerable pains in his legs, accompanied with spots and a large swelling. After taking lemon juice in wine, for some days, he was seized with a severe fit of shivering, upon which he fell into a violent and profuse sweat, which removed the anasarca and scurvy entirely. But in a few days he relapsed into the flux, upon which his anasarcous swellings returned, these continuing after the scurvy had entirely left him. [A] lady, during a tedious recovery after her delivery in child-bed, was seized with universal and severe pains, particularly in the back, legs, and thighs ; she had frequent bleedings at the nose, and her gums were so painful, that she could not chew any solid food ; she became at length so low and feeble, to be seized with a great difficulty of breathing, and a disposition to faint away upon the least exertion of her strength… The nature of her disorder being quite obvious, I discontinued all her former medicines, and by the same acid and vinous draughts, as in the former case, this lady, from a dangerous condition, was restored to a perfect state of health. (p.528) But the most frequent concomitants of the scurvy, and which require our particular attention, are, dropsical swellings in almost every part of the body ; these are often very difficult to remove, and sometimes prove fatal. Weak, aged, and scorbutic persons, are subject to a cough, swellings of their legs, and sometimes even of the face, all which I judge to proceed from serum extravasated in those parts. … when a considerable quantity of water is accumulated in the breast, it will sometimes, without any other cause, give rise to a violent and incessant cough, attended with a constant spitting of gross phlegm, of which I have seen several instances, and sometimes it produces so great a difficulty of breathing, that the patient cannot lie on bed, but must sleep in an erect posture. The peripneumonia notha, which so often puts an end to the life of old men, sometimes proceeds from this cause. In several young persons, who have died consumptive, the lungs seem to have been chiefly injured by being steeped or macerated in the water contained in the breast ; and in others, the waste of substance in the lungs, it is not improbable, may be owing to their peculiar structure ; for as in a general decay of the body, some parts seem to suffer more than others, so, next to the omentum, the lungs are often found to be the organ which corrupts, and is consumed soonest. 114 Œdematous swellings of the legs, accompanying these disorders of the breast, are the surest signs of water being in that cavity. This water may sometimes have no communication with that of the legs, or any part of the body, but it is certainly more frequently the case, in weak scorbutic persons, that water in the legs is received from, and returned again into the cavities of the breast and belly, as I have formerly observed. It must be owned, that the passages for such water, from those cavities into the legs, are unknown to us ; but they are no more so, than the passages for it into the intestines or kidneys, from which sometimes, by slight irritations of those parts, or from other causes, it is plentifully discharged. There is no doubt, but in some scorbutic patients, there is also water even in the joints of the knees. For those scorbutic patients, whose legs were much swelled and œdematous, we prescribed daily a pint of strong beer, medicated with the most powerful antiscorbutic herbs. When the difficulty of breathing was great, and attended with violent fits of coughing at night, we gave at bed-time the salt of tartar, joined with an opiate, in sufficient quantity to procure rest, and to promote a plentiful flow of urine. But, if notwithstanding those remedies, the water increases so much as to impede respiration, and both legs are affected with a soft swelling, which retains the impression of the finger for a considerable time… … dropsy of the breast… SECTION VI: Further observations on the cure. Conclusion. p.533 The scurvy admits not only of various and very opposite methods of cure, but is also often relieved by the most simple means. There are few chronic diseases so painful, and attended with such a variety of alarming symptoms, in which the transitions from life to death, or from sickness to health are so unexpected and sudden ; a removal of the cause often produces an almost immediate effect on the disease. 115 Thomas Trotter (1760-1834) See a list of biographies on the next page. Some brief illustrations of the role of Trotter are extracted here. Porter (1963) in I779 [Trotter] joined the Navy and was appointed Surgeon's Mate to the Berwick, a ship of seventy-four guns, at that time serving in the Channel Fleet. In the spring of 1780 the Berwick sailed for the West Indies in a squadron, but when off Bermuda the squadron was hit by a hurricane, all the ships were dismasted, and some were lost. In great distress the Berwick at last arrived back in England, the crew having suffered greatly from scurvy and dysentery; forty died during the passage back to England and over 200 required hospital treatment on reaching home… As a result of this voyage he became familiar with scurvy–a disease which was to become a major preoccupation with him and one to whose control he was to contribute much. … the war being over… Liverpool, however, was not a bad place for an ex-naval surgeon to find a new ship. It was from this port that most of the Guineamen100 sailed on their horrible trade of carrying slaves from the African coast to the West Indies. At the beginning of June 1783 Trotter sailed as Surgeon of the Brookes… Over nine months of that time had been spent off the coast of West Africa awaiting the cargo of slaves. When Trotter arrived back in England he was so disgusted with the slave trade and his state of health was so impaired from a fever, that he determined never again to sail to Africa in this trade, but he was not altogether finished with slavery. He appeared before a House of Commons Committee set up in 1790 to hear evidence on behalf of the Petitioners for the Abolition of the Slave Trade. In 1793 Trotter was appointed second physician at the Naval Hospital at Haslar and with vigour he set about making many changes in the organization of that institution… Trotter also desired a much larger medical staff for these hospitals. Haslar Hospital, when full, held over 2,000 patients for which there was a staff of 2 physicians, 2 visiting apothecaries with assistant dispensers in the wards for the physical patients, while in the surgical department there were 2 surgeons with assistant surgeons… Trotter had been appointed on 9 April 1794 by the Admiralty to be the Physician to the Channel Fleet, an appointment made, it was believed, solely on his professional ability. Faubert (2023) These records and other notes the surgeons kept became the basis for some of the most powerful evidence presented to the House of Commons Parliamentary Committee on the Slave Trade, such as in 1790, for which Dr Thomas Trotter testified with a decided bias against the trade in human flesh, so horrified was he by his experience during what he called the worst years of his life as surgeon on the Brookes slave ship… Vogel (1933) The largest of his numerous books is “Medicina Nautica” a three decker of 1400 pages embodying his views on naval medicine and hygiene. These included the advocacy of compulsory vaccination and the adoption of a uniform for the seamen, ideas which were duly put into effect after the authorities had given them thoughtful consideration for about fifty years… He distinguished between gonorrhea and syphilis long before the difference was generally understood and opposed the injustice of compelling men infected with these diseases to pay for their treatment. At the risk, as he says, of being found murdered in the streets, he secured the reduction of the licensed gin shops in Plymouth from 300 to one-third of that number. 100 “Such ships were also known as ‘Guineamen’ because the trade involved human trafficking to and from the Guinea coast in West Africa”. https://en.wikipedia.org/wiki/Slave_ship 116 Biographies of Thomas Trotter Faubert M (2023) ‘The Doctor and Devil’: the literary writing of slave-ship surgeons. J Eighteenth-Century Studies. https://doi.org/10.1111/1754-0208.12876 Convertito C (2023) The health of Royal Navy sailors in the West Indies during the American War of Independence, 1776–1783. Int J Maritime History. https://doi.org/10.1177/08438714231218569 Thomson P (2017) The Naval Hospital in Torbay 1800–22. Mariner’s Mirror. https://doi.org/10.1080/00253359.2017.1304705 Burnby J, Bierman A (1996) The incidence of scurvy at sea and its treatment. Revue d’Histoire de la Pharmacie. https://www.persee.fr/doc/pharm_0035-2349_1996_num_84_312_6243 Sheridan RB (1981) The Guinea surgeons on the middle passage: the provision of medical services in the British slave trade. Int J African Historical Studies. https://www.jstor.org/stable/218228 Crellin JK (1966) The health of seamen, selections from the works of Dr. James Lind, Sir Gilbert Blane and Dr. Thomas Trotter. Med Hist. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1033653 Porter IA (1963) Thomas Trotter, M.D., Naval Physician. Med Hist. https://doi.org/10.1017/S0025727300028180 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1034809 Vogel K (1933) Scurvy – “The Plague of the Sea and the Spoyle of Mariners”. Bull N Y Acad Med. https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/19311878 Taylor JS (1920) The founders of Naval hygiene: Lind, Trotter, and Blane. U.S. Naval Medical Bulletin 14:563-628. https://doi.org/10.5281/zenodo.10604304 https://archive.org/details/unitedstatesnava14unit/page/562/mode/2up Rolleston HD (1919?) Thomas Trotter, M.D. Reprinted from contributions to medical and biological research, dedicated to Sir William Osler. https://wellcomecollection.org/works/p42h3gek (pp.153-165) https://archive.org/details/b30622013 https://doi.org/10.1136/jrnms-5-412 (pp.411-419) J Royal Naval Medical Service. https://wellcomecollection.org/works/rsvxejq3 https://archive.org/details/b30622037 Cockburn A (1845) Biographical sketch of the late Dr Trotter, physician to the British Fleet. Edinb Med Surg J. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5792981 https://archive.org/details/b30387310 https://en.wikipedia.org/wiki/Thomas_Trotter_(physician) 117 Vale and Edwards (2011) 248 pp. Physician to the Fleet: The Life and Times of Thomas Trotter, 1760-1832 https://boydellandbrewer.com/9781843836049/physician-to-the-fleet https://www.jstor.org/stable/10.7722/j.ctt81v29 https://www.cambridge.org/core/books/physician-to-the-fleet/E11E1FC528B8F62F0463CBE65B92F7E5 Book Reviews Bowden-Dan (2011) https://doi.org/10.1177/084387141102300280 Babor (2012) https://doi.org/10.1111/j.1360-0443.2011.03761.x Berkowitz (2012) https://muse.jhu.edu/article/471605 Brockliss (2012) https://doi.org/10.1017/S0025727300000363 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3314891 https://scholar.archive.org/work/aqcc2cortvcc3ectbwk6qkt35y Wickenden (2012) https://doi.org/10.1136/jrnms-98-33 118 Thomas Trotter. Observations on the Scurvy (1786/1792) Observations on the scurvy ; with a review of the opinions lately advanced on that disease, and a new theory defended on the approved method of cure, and the induction of pneumatic chemistry. Being an attempt to investigate that principle in recent vegetable matter, which alone, has been found effectual in the treatment of this singular disease ; and from thence to deduce more certain means of prevention than have been adopted hitherto. 1st edition 1786 (Section I pp.17-44) https://archive.org/details/b31875324 https://archive.org/details/b21522819 https://archive.org/details/bim_eighteenth-century_observations-on-the-scur_trotter-thomas-1786 https://babel.hathitrust.org/cgi/pt?id=ucm.5327142552&seq=1 2nd edition 1792 (The History of Scurvy pp.33-70) https://archive.org/details/b3308578x_0002/page/n41/mode/2up https://archive.org/details/b3308578x_0001/page/n39/mode/2up https://archive.org/details/b21947855/page/n39/mode/2up https://archive.org/details/observationsonsc00trot/page/n43/mode/2up https://archive.org/details/bim_eighteenth-century_observations-on-the-scur_trotter-thomas-1792 https://archive.org/details/2575040R.nlm.nih.gov The pages are from the 2nd ed (1792) The History of Scurvy pp.33-70 p.39 Many species and subdivisions of Scurvy are to be found in the writings of physicians… We are now well assured that there is but one Scurvy ; the same in its symptoms, however, at different times variously produced ; and the same method of cure is equally to be pursued, whatever were its causes. p.43 As a methodical plan has been adopted throughout this Work, in narrating the symptoms, I shall divide them into two stages ; the mild and inveterate [I and II]… I. It is, I believe, very generally remarked in a long voyage at sea, when the stock of vegetables is consumed, that there is a constant craving and longing desire for fresh vegetables, particularly the acid kind, for pure water, and p.44 independent of the anxiety which may be excited by the wish of accomplishing the business of a voyage, there seems also a desire of being on land, and is connected with a state of body at the time. I have uniformly observed it the harbinger101 of Scurvy. Dr. Lind, in some part of his Work, has mentioned this circumstance ; but I consider those longings as the first symptoms and the constant attendants of the disease in all its stages. The cravings of appetite, not only amuse their waking hours, with thoughts on green fields, and streams of pure water ; but in dreams they are tantalized by the favourite idea ; and on waking, the mortifying disappointment is expressed with the utmost regret, with groans, and weeping, altogether childish. It is curious to hear them in conversation with one another on these subjects ; I have remarked it as earnestly conducted, as we sometimes observe hypochondriacs in relating their feelings, from any ruffle of temper occasioned by changeable weather, or other slight causes. When I 101 A thing that shows that something is going to happen soon 119 p.45 heard a sailor expressing these desires, and lolling in corners from the sight of his officers, there was always an expectation of his being added to the list of scorbutics in a few days. This scorbutic Nostalgia, “in absentibus a patria, vehemens eundum revisendi desiderium,” belongs to the second species of Doctor Cullen’s Genus. About this time the colour of the face is changed, and even other parts of the skin grow sallow ; the cheerful look of the eye, puts on the dull heavy melancholy, and the whole countenance is, as it were bloated. An universal lassitude prevails not to be refreshed by sleep ; feebleness of the joints of the knees and arms ; pains all over the body, often worse in bed, particularly in the shin bones, which resemble venereal pains. The patient if he attempts to do any thing is soon fatigued ; he grows inactive, his spirits flag ; he flies into hiding places from his duty, broods over his own feelings in solitude, and indulges the most p.46 gloomy ideas of his safety, as if hypochondriacal. To these symptoms generally succeeds the softness of the gums, which so especially characterises Scurvy ; they swell, grow spongy, and bleed from the slightest cause. The breath is fœtid and disagreeable, and often attended with some unpleasant taste of the mouth. The surface of the body is dry and rough to the touch, the pores of the skin are evidently constricted, and the patient feels the external air colder than usual. Some degree of tightness is felt about the breast ; a difficulty of respiration also takes place on using exercise, but commonly inconsiderable in this stage. All the symptoms now mentioned, in some cases increase rapidly ; while in others they make little progress even for weeks : but this depends on the state of the body, and the nature of the diet in use ; nor are they by any means regular in succession. In one person it shall be first known, from the surface of an ulcer being cop.47 vered with a portion of crassamentum102, which is soft and fungous, and on being separated a similar substance is shortly produced : the sailors call this spongy mass the bullocks liver, which it resembles in colour and consistence. In other cases we see it begin, with swellings of the lower 102 Blood clot extremities, which retain the impression of the finger : sometimes a hardness of the muscles will appear before any other sign of the disease ; particularly a degree of rigidity and contraction of the ham-strings. This symptom often deprives the patient of the use of his limbs, and will remain in some cases for weeks after every complaint has disappeared. The Scurvy however soon expresses itself by its more general attendants, as the livid spots, bloated looks, spongy gums, &c. II. As the Disease advances, the lassitude, languor, and debility become more considerable ; the pains in different parts of the body more severe. The respiration is oppressed on the p.48 slightest exertions, with a proneness to faint in an erect posture, and on being exposed to air colder than the temperature they had just before breathed. It is not uncommon for sailors affected with Scurvy to walk upon deck, and drop down irrecoverably ; though to outward appearance when below there seemed no danger. A carpenter’s mate in the Berwick, got out of his hammock without any assistance ; while putting on his jackets as he stood, he grew faintish and fell down : the people about him instantly opened the port, as they thought, to give him free air, when he immediately expired. The fetor of the breath now becomes intolerable : pieces of the gums, or cloats of blood, like spongy flesh, fall out of the mouth : the teeth are loosened in their sockets, and frequently drop from the jaw bone, while the patient is eating : as the gums decay a salivation comes on. The spots on the skin increase rapidly in size, and their colour is variously modified, from yellow to a livid hue, by effusions of blood in the cellular p.49 texture. Every slight scratch or division of the skin, is apt to degenerate into a foul ulcer, and old cicatrices are apt to break out afresh. Hemorrhagies are now frequent from different parts of the body ; but particularly from the nose, or from the ulcers : though the loss of blood has been small, there are many instances, where it seemed to hasten the death of the patient, which has happened immediately after. The belly is generally costive103 ; but diarrhæas, and even fluxes are not uncommon. The urine, as might be expected, is highly coloured ; the disease, in its most inveterate degree, happens 103 Constipation 120 when water is scarce ; therefore, for want of dilution, the urine is small in quantity, and acrid. Nothing satisfactory is to be learned from the state of the pulse ; but is often to be felt regular a very short time before death. The mind in the beginning as has been remarked, and throughout the disease, is timid, anxious, and desponding ; but towards the fatal period, there p.50 is generally a total indifference and seeming torpor of every faculty. The appetite for food in every stage of Scurvy is seldom impaired ; the patient has been even known to expire with the bite in his mouth. Such is the History of Scurvy, as it generally makes its appearance in his Majesty’s ships of war. I shall now describe the disease, as it broke out on board of a slave ship, attended with many singular phenomena never before related ; which shew in an emphatic manner, under what unfavourable circumstances the unfortunate Africans are exposed to the horrors of disease, and confinement on ship-board. About the beginning of June, 1783, the Guineaman104, of which I was surgeon, sailed from the port of Liverpool. After a favourable passage of little more than a month, we came to anchor at Cape La How, on the Gold Coast ; having buried a sailor who died of the small pox, p.51 a dangerous distemper in a slave ship ; but by taking proper precautions, and throwing every thing over board which belonged to him, the infection only extended to one black man, a passenger, who was confined in the long-boat till he recovered. No ship had opened trade here since the conclusion of the war ; so that in the space of a week, we had bought more than an hundred prime slaves, young, stout, and healthy. This was thought a lucky beginning ; but when we came to Anamaboe, the trade was scarce, and the price of slaves very high, from the number of vessels then lying in the road, which were eight or ten. So slow was now our purchase, that in February we had not got on board two-thirds of our complement. About this time it was remarked, that the 104. “Such ships were also known as ‘Guineamen’ because the trade involved human trafficking to and from the Guinea coast in West Africa”. https://en.wikipedia.org/wiki/Slave_ship slaves bought at Cape La How, were growing exceedingly fat. On this account it was recommended to the master of the ship, to allow them more exercise, and reduce the quantity of diet, p.52 which had hitherto been too much from a mistaken notion that it would strengthen them the more, to bear the passage to the West Indies. Their food consisted of beans, which were brought from England, and rice and Indian corn, which were bought on the coast. These articles were boiled to the consistence of a soft paste, and made as near as possible like the food of the country by the addition of palm oil, Guinea pepper, and common salt. A crew which held from fourteen to sixteen quarts of this composition, was served to ten of them twice a day : they were allowed to drink what water they pleased ; but, from being confined below, about sixteen hours out of the twenty-four, and permitted no exercise when upon deck ; it was easy to foresee that they could not long remain in a healthy state. Such, however, was the obstinate and conceited105 ignorance of the master of the vessel, that this treatment was still persisted in : the food was continued in the same proportion, till you would have thought that some of p.53 them, with much difficulty walked along the deck. And, though a certain number might have been unfettered106 without endangering the safety of the ship, it was not attended to. The custom of dancing them round the deck to the sound of the drum, was not practiced till it was too late to be of service. It will be proper to observe here, that these poor wretches are shackled in pairs, by the wrists and ancles ; when they come upon deck, two long chains are passed through their irons at the ancle, which reach from the forecastle to the barricade, for the purpose of confining them to one spot. The rooms where they are secured below, are from five to six feet in height, according to the size of the ship ; but besides the number that lie on the deck, about one half as many are stretched on what they call a platform, that runs along the sides of the vessel ; raised about two feet and a half from the floor, and of p.54 breadth sufficient for the length of a man.* *If I am right informed, a section of this ship was laid before the Society for the Abolition of the Slave Trade ; in order to 105 Disapproving 106 Not limited by rules 121 the use of molasses excepted ; but a supply of them did not come in time to our relief. A squadron, of five sail of the line, sailed on the 17th of March, under Admiral Colpoys ; to each of these ships I sent a cask of lemon juice ; at the same time informing the Admiral of my reasons. This squadron, after a month’s cruize, returned to port with many ill of Scurvy, and a general disposition to the disease throughout the ships : some very bad cases were even sent to Haslar, p.409 from the Astrea frigate. (Vide General Abstract of Health.) A squadron, of four sail of the line, returned from the North Sea, under Rear-Admiral Harvey. The Prince of Wales, with a raw crew, and a bad party of soldiers, instead of marines, on board, had sent fifty scorbutics on shore to Deal Hospital ; many of these in the last stage of the disease, five of whom perished in the boat. The cold of the North Sea is generally reckoned more severe than in the Channel ; hence the Prince of Wales and Russel, seem to have had worse cases than with us at Spithead. The Scurvy, towards the beginning of April, had made very considerable progress, particularly in the Excellent, Minotaur, and Invincible. These ships were part of a squadron, ordered to sea, under the Honourable Admiral Waldegrave. I had previously represented the state of the Fleet to the Commissioners of Sick and Wounded ; and demanded a supply of lemon juice, or the fruit in its entire state, to be ready on board the hospital ship, to serve the detached squadrons as they went to sea. This supply not having come in due time, in consultation with Admiral Waldegrave, and by his order, I purchased at Portsmouth seventy pounds worth of lemons and oranges, which were distributed to the squadron. At the same time I informed the Sick and Woundp.410 ed Board, that I did not think these ships were in a condition to go to sea, without being provided with articles for the cure of Scurvy. These ships continued at sea seven weeks, and towards the end of the cruize had a further supply of fruit, which the Admiral ordered to be purchased from a Swedish vessel. The consequence of these precautions were, that many cases were cured at sea, without a single death : but the crews of the whole were much in need of fresh meat and other delicacies, when they returned to port. Admiral Waldegrave was so obliging as to transmit to me, copies of remarks on the fruit, in the treatment of Scurvy by the surgeons of his ships. It was observed in each ship, that by changing the beer for grog, had a quick effect in encreasing the number of Scurvies.109 On board the Excellent, much attention was paid to this circumstance. Captain Collingwood tried it in different ways, and kept a diary of the sick list. Mr. Scott the surgeon, in his report, says, that “they sailed with ten scorbutics in the list ; that this number fluctuated a little while beer was served but when half beer and half grog, it increased to twenty or thirty. When all grog or wine, it encreased from forty to fiftysix. He concluded, with the uniform testimony of others, by saying, that the lemons were a certain cure.” The testimonies of the other p.411 surgeons, viz. Mr. Kent of the Marlborough, Mr. Dods of the Tremendous, Mr. Bell of the Minotaur, Mr. Sibbald of the Nymphe, and Mr. Drew of the Blonde, were to the same effect.* * REPORT of the Effects of LEMONS on board His Majesty's Ship Invincible. “It may be, in some measure, necessary, just to mention the state of health, on board the Invincible, previous to our sailing on the late cruize ; in order to shew, in a clear point of view, the excellent effects of the Lemon and Orange, with which we were supplied. “The Scurvy (the only complaint to be mentioned here) made its appearance at Spithead in the first week of April, in a severe degree. Five patients were sent to the hospital ; others variously ill, to the number of eighteen, at the time of sailing ; four of that number were incapable of duty. By the last of the month, ten more had applied. Those that were worst, took three lemons and one orange, daily ; and the others, two lemons. In every instance, after the third day, and sometimes sooner, they began to recover, and were shortly well. In the beginning of May, patients continued to come down, and were treated in the same manner, with equal good success ; in the course of the month fifty-six had applied, and were recovered, or nearly so : in the latter end of the month, the fruit was all expended ; but there still remained a few gallons of lemon juice, which lasted until the 2d of June. Patients continued to apply, and two of those that had been recovering before the lemons were expended, got worse in the short interval from the 2d to the 5th, the day on which a fresh supply of lemons was received. Their complaints were soon checked by the fresh fruit ; it was not found that they recovered so fast by the juice, though it was given, in some cases, to a pint per diem. To this time, thirty-two had applied ; and every day two or three, variously tainted, had appeared. “It does not appear, at present ; that we shall have occasion to send any men to the hospital for Scurvy, though I am positively of opinion, that if we had not been supplied with the fruit, many of the ship’s company must have suffered greatly, or, perhaps, 109 It is possible that old beers contained some levels of vitamin C, but it is highly unlikely that current beers contain it. https://doi.org/10.1016/S0140-6736(01)04502-0 128 died.— The numbers that complained, and cured, or nearly so, are, in April, twenty-eight ; May, fifty-six ; and in June, thirtytwo : in all, one hundred and sixteen. (Signed) June 8, 1795. T. KENNING, Surgeon.” “Note. In the sketch of the good effects of the lemons supplied in the late cruize, I have not mentioned any thing of the advantage our men had in point of regimen. Previous to our sailing, Captain Pakenham, according to his usual liberality, purchased five guineas worth of onions, and put them under my care. A quantity of fresh mutton was also sent every day to boil with the portable broth. The sick had wine instead of grog. T. K.” p.412 From the circumstances just narrated, it will appear satisfactory, that my fears were not groundless. The prevention of Scurvy was a great object in a Fleet, because we are not aware of the exertions of a restless enemy. But the period was now arrived, when the necessity of checking this ravaging disease became more apparent. It pervaded every ship ; and as the causes which produced it were general in their operation, so it was reasonable to infer, that every seaman in the p.413 Fleet ought to partake of the means of prevention and cure.* * “You will no doubt observe with pleasure, the few scorbutic patients sent to the hospital, in comparison with the number that have complained of that disease. This I can attribute to nothing else, but the timely supply of fruit and vegetables, which were obtained by your order, and which had the most speedy and desirable effect. (Signed) Robust, May 31, 1795. JAMES TURKINGTON, Surgeon.” In my representations I took upon me to explain our condition to the utmost minutiæ of the cause, as well as the method most likely to give us relief. The Lords Commissioners of Admiralty, were therefore pleased to order every thing which was demanded. The fresh beef was served according to the usual allowance, and the salt provisions withheld. A large supply of lemons and oranges were ordered to be sent from the Sick and Hurt Department, equal to our wants. In addition to all these, sallad was ordered to be procured, by way of assisting the other means of prevention and cure. Vegetation was very late, from the coldness of the spring months ; but what could not be commanded in the gardens round Portsmouth, was brought from Fareham and other places. In my official letters, I took care to inform their Lordships, that I had attended the vegetable stalls on market-days, as well as the garp.414 dens in the neighbourhood, and had there found abundance for our consumption. We were, therefore, from the 31st of May, supplied with near five thousand weight of sallad every day, which was distributed, under my own eye, to the different ships at Spithead. The good effects of these refreshments were astonishing ; we had only to regret that they were not sent sooner. They do not rest on the official testimony of the surgeons only ; the whole of our officers attended to the recovery of their people, with every mark of affection : they had sought and conquered together, and were now from habit like persons of the same family. About two hundred men in Scurvy, had been sent on more, during the early appearance of the disease ; but from the time of being supplied with fresh meat, fruit, and vegetables, it was not necessary to move them from the ship. The officers and surgeons agreed, that their men were cured in a shorter time on board. But more urgent reasons required to keep them on board ; desertion was prevented, indolent habits soon learned in our hospitals, were not so apt to appear under the eye of their own officers, and as equal justice would be done to the cure ; our ships thereby remainded ready for service. Thus, were those valuable men fitted and recruited for duty, at an expence to Government p.415 too trifling to be mentioned. It was amply repaid, in a very short time, by the capture of three sail of the enemy’s line, in the very mouth of a French harbour, by Lord Bridport. But it ought to be remembered, that these ships could not have sailed a week sooner, from the people that were laid up with Scurvy bearing a large proportion ; to such an extent had it prevailed every where. Some deaths happened at the hospital in this disease ; I believe not more than one or two ; but not a single one on board, either at sea or at Spithead. Although the health of the people was so much recruited when Lord Bridport sailed ; yet it was plain, that the disposition to Scurvy was not sufficiently corrected, which would have required a continuance of the sallad for a longer time. But to guard against the effects of salt diet, and any accident that might detain the squadron at sea, every ship was supplied with thirty gallons of lemon juice from the Charon, besides some half chests of fruit, to those that were most in danger from a return of the complaint. The London, Valiant, and Colossus, that had suffered so much, 129 were now in perfect health. The weather, for the season, was cold in the early part of the cruize. On the 10th of July, the hospital ship parted from the squadron, having received the sick, and forty-five wounded men, p.416 to carry home. At parting, some of the surgeons were served with an additional supply of lemon juice from the Charon, lest it should be wanted before our return. On the 15th of August we returned to Lord Bridport, having on board a number of sheep, Vegetables, &c. I visited every ship in the course of the day, and found the Scurvy beginning in all ; even the frigates had many cases of it. We have seen, in Admiral Waldegrave’s squadron, the rapid increase of Scurvy, as soon as the beer was done ; it was also observed in Lord Bridport’s.* * This is an incontrovertible argument, in favour of my proposal for beer of a stronger body. A ship would be able to carry eight weeks allowance to sea : if the cruize or passage was longer, it might be served alternately with wine ; by which means, a ship going to the East or West Indies, might prolong it to their arrival at the place of destination. We should then have no condemned beer ; for a little more hop, and being stronger in quality, would make it keep. I would have a quart served in the forenoon, and another in the evening. In the warm summer of 1794, the beer that became unfit for use in our Fleet, exceeded all precedent for the immense quantity. I have even remarked at Spithead, some ships, that indulged the seamen more than others with spirits from the more, have on that very account a longer list of scorbutics, and with more aggravated symptoms. This fact gives considerable force to my former arguments on the theory of Scurvy. The use of spirits in the drink p.417 of the sailor, called grog, manifestly tends to abstract the oxygene from the body : from a deficiency of this principle, I apprehend the disease is produced.* * Observations on Scurvy, second Edition. Longman, London. After Lord Bridport’s squadron had been ten weeks at sea, it then appeared how much the safety of our men depended on the citric acid. There was not a case, in which it was given, where it did not produce a cure in the space of a few days.* * “I have no remarks worthy of insertion, except additional proofs of the most happy effect, from the use of lemon juice : not only in scorbutic affects of the extremities, but in pneumatic attacks, when a scorbutic diathesis prevails. (Signed) Pallas, Sept. 20, 1795. R. HARRISON.” The Robust, at anchor in Quiberon Bay with Sir J. B. Warren, was obliged to leave the station from becoming so over-run with Scurvy. Some of her people sunk under it, from not sending to the Charon for a fresh supply of the lemon Juice.* * See Mr. Turkington’s Report in the General Abstract of Health. Vinegar was carefully served to the messes of seamen throughout the squadron, to be used with the salt meat : yet in those ships where the men p.418 took it in large quantities, it was not observed to retard the advancement of the disease. Even porter failed to cure. There was now another cause that accelerated the approach of Scurvy. The ships had been so long at sea, that there was a necessity for curtailing the allowance of water : the number of scorbutics increased in a great proportion ; and the London and Prince George were obliged to leave the Fleet. These ships made for the first port, and arrived at Plymouth in the beginning of August. Mr. Smith, of the London, sent eighty cases of the Scurvy to the hospital, and thirty in other diseases. Mr. Harris, of the Prince George, sent four men in various complaints. The purser of the latter ship was generous enough to supply so large a proportion of vegetables, that two hundred scorbutics were cured on board, and the disease effectly subdued among the crew. The condition of the two ships, both second rates, affords a valuable lesson on service : the London not having the means of curing her people on board, by having only an acting purser, who was not empowered, lay inactive, for a length of time, in Plymouth Sound ; and many of her men never returned from the hospital. The Prince George, from the bounty of a single individual, was enabled to cure her seamen in the ship, and sailed for Portsmouth, in less than four weeks, in perfect p.419 health, to receive the flag of Rear-Admiral Christian, destined for the West Indies. Thus we see, as certain measures predominate, that the Navy of Great Britain may be occasionally disabled, or rendered active. — Reasons similar to those now assigned, made the Robust leave sixty men at Haslar, when she sailed a second time for Quiberon Bay. This is one of the greatest misfortunes that can befall either a ship, or the people left behind.* * The Anson frigate, Captain Durham, one of Sir J. B. Warren’s squadron, was obliged to go to Plymouth in July 1795, being overcome with Scurvy. She landed eighty seamen, and was 130 under the necessity of leaving a number behind, when she sailed for Quiberon Bay a second time. Not having received vegetables while in port, sufficient to subdue the general taint among the crew, the disease quickly re-appeared ; and had t[here] not been for very large supplies of lemon juice from the hospital ship, she must either have returned to England again, or buried half her people in Scurvy. The ship’s company is replaced by draughts of raw men from guardships, or another ship is broke up to recruit the other. The sick that were left on more, when recovered, are sent to a guardship, perhaps not famous for good order ; and in the end they are scattered into strange ships, where they have a new acquaintance to form, and where new officers, perhaps, inculcate very different modes of discipline to what they have been accustomed : such are the resistless arguments that may be produced, to p.420 justify the propriety of serving the seamen with every comfort in their own ships.* * Mr. Perry, then surgeon of the Adamant, sent me some Spanish onions, which he had brought, in the winter, from Cadiz. In order to preserve them, he cut the root off to the quick, and applied a slight solution of lunar caustic to the wound, which checked their vegetation so much, that one of them lay in my cabin window for six months, without shooting. This philosophical experiment may be easily accomplished by a hot poker, or any piece of iron, with which the roots should be effectually seared. Country people are in the custom of running a red hot knitting needle from the root to the top of the onion, which answers better. These processes preserve this vegetable for a length of time, and as it is one of the most useful at sea, they cannot be too generally known. On the 19th of September, Lord Bridport’s Fleet arrived at Spithead. The only disease that was known in the ships, was the Scurvy. In the General Abstract of Health, I have mentioned the number in each ship ; but every one on board might be considered as labouring under some degree of the disease. Large supplies of vegetables were served throughout the whole ; and from the quantity of lemon juice being diminished, the surgeon of the Charon was directed to purchase, at the Isle of Wight, fifty bushels of apples, in the immature state. The lemons indeed were now so scarce, and the consumption of the juice had been so great, that little was left in the kingdom. We were therep.421 fore very glad to procure the apples, as a substitute. The Royal Sovereign, in particular, reaped much benefit from them, and did not send a single patient on more. Mr. Kein found his people well satisfied : I was indeed glad of the change of fruit ; for I was tired with seeing the poor fellows drinking constantly of the lemon juice. The cure was every where so compleat in ten days from the arrival, that we had nothing left, but the slightest remains, to show Earl Spencer, when he visited the Fleet on the end of the month. On the 6th of October, the hospital ship joined the squadron under Rear-Admiral Harvey, off Belle-isle ; when the sheep, vegetables, apples, lemon juice, and porter, was distributed to the ships for the use of the sick. This squadron put into Quiberon Bay, and lay at anchor there, except a short cruize, till the end of December. During this time, fresh supplies of cattle, sheep, and vegetables, were frequently sent out ; so that the Scurvy was kept under, or cured when it appeared, with little trouble, by the lemon juice.* * “I am opinion, that the lemon juice that was served out to our people three or four times a day, diluted with about two ports of water, and a suitable proportion of sugar ; with the timely supply of vegetables and fresh meat, received while the Fleet remained in the Bay, and issuing of wine a considerable part of the time, checked, and in a great measure prevented, our people from being afflicted with Scurvy, and other disorders. (Signed) R. FORREST, Surgeon.” Prince of Wales, Jan. 2, 1796. N.B. Thirty cases of Scurvy appeared in the Prince of Wales during this absence of nineteen weeks from England ; but there were more in the other ships of the squadron. T. T. p.422 These ships came to Spithead on the 2d of January 1796, and with a squadron, just arrived, under the command of Vice-Admiral Cornwallis, were supplied, on fresh-meat days, with a large allowance of vegetables. This allowance was continued to all our ships, for a fortnight after coming from sea. From this period we may date the extinction of Scurvy in the Fleet. We have thus seen, from the effects of a cold and rigorous winter, the impolitic and considerate measure of reducing the allowance of fresh beef, in harbour, and the destruction of vegetation by frost, a Scurvy induced, so general in its extent, as to endanger the safety of the whole Channel Fleet of Britain. The practical inferences to be drawn from this narrative are obvious. It appears highly expedient, that a Fleet just come from sea, should have the people recruited for future service in as short a time as possible. p.423 However vague and uncertain the records of naval transactions left this point on former occasions the late occurrences of the Channel Fleet, 131 have efficiently established the fact, that Scurvy can always be prevented by fresh vegetables, and cured effectually by the lemon, or the preserved juice of that fruit. In the General Abstract of Health, I have mentioned, that Dr. Archibald Thompson, of the Valiant, found, upon comparing his cases, that not a man who shared of the large allowance of lemons and sallad at Spithead, towards the end of May and the beginning of June, had the least symptom of Scurvy during the long cruize with Lord Bridport. Mr. John Smith, of the London, on comparing his cases, found, that only five of all that he sent on shore to Plymouth Hospital, were of the number who partook of the former refreshments at Spithead, and for these he gives reasons. I think it proper to mention these two ships, because they suffered more than others, from the disease in April and May. Their respective surgeons took also much trouble to ascertain the fact, with sufficient clearness, on my suggestion.* * “London, Jan. 6, 1796. “SIR, “According to your request, I have examined my books very carefully, and find only five men who had the Scurvy in April and May, sent to Plymouth Hospital in September, after more than three month’s cruize. Three of them had a scorbutic flux ; and two had blotches, &c. on their legs, with other symptoms. One of these had but lately recovered from a venereal complaint, being six weeks under cure : the other was always of a sickly habit. “Two out of the eighty sent to Plymouth Hospital, in September, for Scurvy, had been at Haslar Hospital in April and May. One of them was sent for a scorbutic flux ; the other had blotches. &c. I am, SIR, Your most obedient servant, (Signed) John Smith. To Dr. TROTTER, Physician of the Fleet.” p.424 Whatever, therefore, may be the theory of seascurvy, we contend, that recent vegetable matter, imparts a something to the body, which fortifies it against the disease : and that in proportion to the quantity of this something imparted, making allowance, at the same time, for external causes, which counteract its effects on the constitution. the symptoms will sooner or later appear. The preservative means ought, therefore, to be attended to, and we ought to trust only to the vegetable acid, when we can do no better.* * It is the custom of service, for the purser to order his steward to buy vegetables, greens, or cabbages, for the fresh beef broth out of his necessary money : but there is no fixed quantity. There is a necessity for fixing the proportion, cost what it may. Why is an article of diet, that is the best security against a fatal disease, left to such uncertainty, or liable to be withheld by any individual, when its price becomes a little higher than common ? p.425 The juice of lemons long continued, tends to weaken the stomach and general habit, and produces emaciation in proportion to the length of time it is used. We have also found, that the preserved juice is very inferior to the fruit, in its intire and recent state ; although, I believe, that great attention was paid to its preservation, and when there could be no suspicion of vinegar, or other acids, fraudulently added. Three dozen of sound lemons did generally as much as a gallon of the juice. Yet we have seen, in Mr. Moffat’s report, that he had cured many with the juice that had been near two years squeezed from the fruit.* * This general Scurvy in the Fleet, would have afforded a fine opportunity for trying the effect of oxygene air in the cure. But, as I was the first who ventured to publish the Theory, there was a danger of being accused of a prediliction for speculative opinions, had I applied to Government for an apparatus. We have, from this practice, established another fact, of the first importance in naval operations. We have often heard people talk of land air, and land recreations, for the Scurvy. There p.426 is not at present an officer in the Fleet, that, in doing justice to either his people or his country, would prefer the cure out of a ship. Nay, there is often the most urgent necessity for keeping them on board till they acquire a certain degree of strength. In the very weak stage, a scorbutic patient cannot bear the external air, which has been long observed, and recently confirmed, by the five men dying in the boat belonging to the Prince of Wales, between the Downs and Deal Hospital. Those who may consult these pages, and are acquainted with the opinions, which I formerly published, on the Theory and Practice of Sea Scurvy, will see, that this immense field for observation, which the Channel Fleet has afforded, seems to strengthen all my old conclusions. Nothing remains for me to retract. The whole has been confirmed by the experience of a great number of surgeons, of approved abilities, in the profession. Dr. Beddoes, in his remarks on my work, laid much stress on the impure air of ships in producing Scurvy. If this had so much effect, surely it would have counteracted the cure, when the seamen remained on board : but that has not been observed. The surgeons generally remarked, 132 a very great difference on the second and third day ; and a week was long enough for to comp.427 pleat the cure. The discipline of the officers in the Fleet, in whatever related to health, has rendered them famous. To have thought of foul air, as a cause of the Scurvy, when it appeared in the Royal George and Queen, would have been the last resource of a physician, investigating causes, who had witnessed the admirable system of duty practised by Captains Domet and Bedford. I shall conclude my observations on this disease, by introducing a letter from Mr. Baird, surgeon of the Hector. This ship left the Channel Fleet in May, when our sufferings were great. “Hector, Spithead, Dec. 4th, 1795. “SIR, “As I consider the Navy indebted to your exertions, for the very valuable institutions of lemon juice ; I should think I failed in my duty, if I did not communicate to you, the wonderful benefit derived from it in the Hector. “On my joining this ship, in May last, I found her under orders for foreign service ; our destination supposed to be the East Indies. Several of our ship’s company were labouring under Scurvy, in an advanced stage, all of whom I sent to the hospital, previous to our sailing. But, as I p.428 had great reason to suppose, that the scorbutic taint was general, I rather felt discouraged at the idea of encountering so long a voyage, under such circumstances. Indeed my fears were soon confirmed ; for we were but a few days at sea, when the sick list was considerably increased with scorbutic patients : some with their gums highly-putrid, legs and thighs much swelled, hams contracted, and so very ill, as to render them totally unfit for any kind of duty. The small beer not being expended, the instructions from the Sick and Wounded Office did not exactly warrant my issuing lemon juice and sugar. But, as it seemed the only probable remedy, I solicited Captain Montague to lose no time in giving it to the ship’s company, in the quantity directed, as a preventive ; to be mixed with a proportion of water, as sherbit ; and also to allow me to issue it, in any quantity I might think proper, in bad cases. “I began with giving the lemon juice, in the quantity of an ounce and half daily ; and, encouraged by the material change I perceived in about four days, I increased it to three or four ounces per diem ; always taking care to join a sufficient quantity of sugar, to prevent it from irritating the bowels : in twelve or fourteen days, the worst of them were able to return to duty ; p.429 every symptom being then removed, except some slight degree of stiffness in the hams, which gradually wore off. “That the lemon juice was equally serviceable as a preventive, as I think evident from the following observation ; for the first month, new patients frequently complained, but after that time, the only scorbutics we had, were men pressed out of merchant ships returning from long foreign voyages. “We sailed with the outward bound East India trade on the 24th of May last ; and returned the 19th of November, with the home-ward bound trade ; having been as far as 28° and a half south ; about three weeks in harbour from the time of sailing till our return ; and part of that time at St. Helena, a place well known for its barrenness, and the very little refreshment which it produces. We have returned to Spithead without losing a man by Scurvy ; nor have we had occasion to send a single man, in that disease, to the hospital. “When I consider the alarming progress which the Scurvy was making among the Hector’s ship’s company, previous to the administration of lemon juice as a preventive ; the sudden check that disease met with afterwards ; the powerful effect of the acid in very bad cases ; I think p.430 I will not be accused of presumption, when I pronounce it, if properly administered, a most infallible remedy, both in the cure and prevention of Scurvy. I am, SIR, Your most obedient, and humble servant, (Signed) A. Baird.” To Dr. TROTTER.” 133 Medicina Nautica 2nd ed (1804) Vol III. (Scurvy pp. 387-402) https://archive.org/details/b33088810_0003/page/386/mode/2up https://archive.org/details/b21351879_003/page/386/mode/2up p.387 There is no part of my medical labours that has afforded me more satisfaction, than what relates to the prevention and cure of scurvy. A case of scurvy simply, requiring to be sent to an hospital, has not come under my observation since 1795. The disease has, no doubt, appeared in numerous instances ; but, the preserved lemon-juice being now a part of the surgeon’s stores, and regularly supplied when demanded, the certain relief is at hand. When I contrast the present state of the Channel fleet with what it was many years ago, even in my own early days of service, there is much reason for exultation. It was no uncommon thing in those times, for a ship, during in eight weeks cruize, to bury ten or twelve men in scurvy, and land fifty at an hospital. There was an instance last war, where so many were landed at Haslar, on the fleet coming from sea, that the hospital could not contain them ; they were lodged in the chapel, and in tents erected for the purpose. Such was the inveteracy of the p.388 disease on that occasion, that many died in the boats between Spithead and the hospital ; and in the hospital also many perished. When I look over Lind’s Work on Scurvy, it much astonishes me to think how he met with so many subjects for dissection. The plain truth of the matter is, his method of cure was imperfect ; for a man dying of scurvy is not known in the present day. It may be justly deemed a confirmation of a successful practice, that nothing but the most unprincipled neglect will ever in future provide a scorbutic corpse for dissection. In my former Volume, an instance is narrated of twenty men dying in scurvy on board an EastIndiaman,110 in the passage between India and the Cape of Good-Hope. When I think of the immense riches of that company of merchants, I am chilled with horror at reflecting on a fact that stains the commercial character with indelible disgrace. 110 East Indiaman was a general name for any sailing ship operating under charter or licence to any of the East India trading companies. https://en.wikipedia.org/wiki/East_Indiaman I am afraid that occurrences at this kind are very frequent in the ships of the East-India Company : Indeed the whole trading ships of this country require correction in this point. It is the nature of Trade to render man selfish ; to chill the heart and narrow the affections. A commercial nation like this ought to have a Board of Health, to protect seamen in distant voyages, so constituted under legislative authority, that the power of gold could not abridge its benevolent spirit. Much, however, as I depend on the citric acid111 for the cure of scurvy, I must still assert, that the prevention ought to be trusted to esculent vegetables, if they can be procured. In the warm climates, where these fruits grow, they may be used by the seamen with equal pleasure and advantage in their native state ; but it is unnatural, in p.389 the winter months of our climate to give a man lemonade. This practice was introduced to the Channel fleet, in the summer of 1800 : the scurvy, for the five preceding years, was little known, as the people had abundant supplies of vegetables on coming to port. But if it was determined that the ships should not remain long enough in port to consume the quantity of cabbage, onions, &c. to recruit their health, it was an easy matter to let them carry them to sea ; or when at sea to send out regular supplies. This was done in the latter part of the summer of 1800 ; partially in the winter ; but better attended to in 1801, when the supply was greater, and with it regular cargoes of bullocks sent off Brest. From the whole of my reports from the surgeons of ships of the line, I do not find a single fact that can justify the general use of lemon-juice as lately administered. As in all former cruizes, unless the supply of vegetables was frequent and large, cases of scurvy I found still appeared that required the acid in larger quantity from the surgeons. Indeed it is pretty certain that what was called lemon-juice in the victualling-office, was only acetous acid and lemon-juice mixed. The importation of lemons to this country must have been unequal to the expenditure in the navy only. 111 Here “citric acid” probably means acids of citrus fruit, though Trotter was also interested in the substance “citric acid”, see below 134 But it is also probable that if the juice was unadulterated, it had been weakened and diluted by other means. The long cruizes, and restless mode of duty in the fleet, in 1800, joined to the use of this cold and fat-consuming beverage, had reduced the strength and vigour of body in a wonderful manner in every ship. But the better-conducted supplies of beef and vegetables, which began in May 1801, restored the emaciated people, made p.390 them equal to all the exigences112 of duty, and renewed the flush of health on their cheeks. These supplies were the more desirable, as an immense proportion of the whole had been debilitated by the typhous fevers which prevailed in the winter and spring months ; fevers which weaken a constitution more than almost any other disease.—It is thus apparent, how imperfect many forms of service still remain, that relate to the subject of health : nothing yet is done by system. In my former animadversions113 on scurvy, I pointed out the pressing necessity for supplying all transports with every preventive to ward off the disease, with a copious allowance of lemon-juice for cure. Large armies have been embarked at different times, during the war, yet these securities against a fatal disease are still little attended to. If we observe seamen accustomed to a sea-life so liable to suffer from scurvy, how much more ought we to guard against it among raw soldiers? A party of artillery, that formed part of the army of Sir James Pultney in 1800, was in the spring encamped on an island in Quiberon Bay, where the whole must have perished, but for lemon-juice sent from the men of war. The scurvy, after this, appeared, as might have been easily foreseen, throughout the whole army ; which must have retarded its operations, and run great hazard in defeating the Egyptian enterprize. In this Volume, in Mr. Perkins’s report,114 we observe two symptoms are mentioned, which are new to the history of scurvy ; viz. leucorrhœa and strangury in the women on board L’Uranie. The 112 Need, demand, requirement 113 Criticism or censure; a carefully considered observation 114 p. 102, Perkins: “The women suffered from this disorder also; and in addition to the accustomed symptoms, strangury and leucorrhœa were peculiarly distressing.” [TT] These last symptoms are new to our history of the scurvy; and strongly mark the difference of morbid action in the female constitution, in both solids and fluids. https://en.wikipedia.org/wiki/Strangury female, as being seldom at sea, has scarcely been the subject of this disease. The lax and debilitated solid might, no doubt, account for this change in the catamenia, but when the blood p.391 itself is evidently altered in colour, from the abstraction of oxygene, which imparts the florid complexion to the vital fluid, we can the less wonder at any alteration in the uterine effusion. ———————————————— Thus far the history of scurvy appears complete in what relates to the prevention and cure. But there was still a desideratum ; some method of preserving the citric acid was wanting, that to a certainty could ensure the antiscorbutic power for any length of time, and in any climate. The juice we have seen, as preserved for the navy, cure scurvy after being two years in bottle ; this is very fair : but still it is uncertain in that form for preservation, as it is liable to fermentation. Due attention, I believe, has by no means been taken to give it even the best chance for keeping in this form. No case of lemon-juice comes to the fleet where there are not a number of bottles with the pulp and rind115 bruised down and mixed with the liquor. This, I suppose, is done by the contractor by way of making up the quantity as cheap as he can. But this very pulp, and mucilage which it contains, are what produce the fermentation that destroys the native acid. Besides, the acid may be so diluted and weakened by the addition of pure water, so as very much to disappoint us in the cure, unless exhibited in very large quantity. When mixed with acetous acid, I believe no chemical test can decide the sophistication. In the spring of 1800, I observed in the newspaper an advertisement by Mr. Coxwell, chemist, of Temple Bar, for a crystallized form of lemonjuice ; and very soon after saw some of it in the possession of Mr. Kittoe, purser of his Majesty’s ship p.392 Centaur ; and which I conjectured to be prepared according to Scheele’s method. I was therefore induced to write to Mr. Coxwell, and to inform him, that if he would send me some of his salt for experiment in the cure of scurvy, I should take care to intrust it to surgeons that were capable of exhibiting the medicine so as to appreciate its powers, that he might avail himself of my authority, should it prove successful. In the meantime, the honourable R. Admiral Berkley, whose heart is always expanded to give relief to a sick sailor, had interested 115 Skin, peel, outer layer 135 himself in the business, and desired Mr. Coxwell to forward to me a quantity of his preparation sufficient for trial. This form of the citric acid was first invented by Scheele, the late celebrated Swedish chemist, and published in Crell’s journals for 1784.116 He tried the process which he had several years before discovered for purifying the acid of tartar, and obtained the acid of lemon, pure and concentrated. Mr. Coxwell had now the credit of preparing, on the largest scale, what had hitherto been confined to the laboratory of the chemist only.117 At the very time that Mr. Coxwell’s parcel came into my hands, the Superb, of 74 guns, arrived in Cawsand bay, uncommonly affected with scurvy, The first case that I inspected seemed exactly fitted for the trial : He was, as Mr. Watherston emphatically expressed, sent by Providence for the purpose. Such an inveterate disease had not been seen in the fleet for years ; the symptoms had advanced so rapidly as to approach the last stage ; and, what was rather surprising, he had first sought relief only about two hours before. I shall detail the case as related in Mr. Watherston’s diary, who, at my request, noted the diet, that all circumstances p.393 might be duly weighed in adjudging the merits of the concrete acid.* * “Case of scurvy treated by the concrete citric acid. Superb, July 5th, 1800. Robert Brown, aged 21, seaman, labours under an advanced stage of scurvy, the principal symptoms of which are, spungy, livid, and ulcerated gums, which bleed frequently ; contractions of both hams, but particularly of the right one, in which there is a considerable degree of rigidity, hardness, tumefaction118, and livid discoloration, with a number of large blotches upon the leg ; has used no medicine except two ounces of lemon-juice… His diet to-day has been bargou for breakfast ; salt beef and pudding for dinner ; bread, butter, and cheese for supper. 116 Carl Wilhelm Scheele isolated citric acid from lemon juice in 1784. https://www.acs.org/molecule-of-the-week/archive/c/citric-acid https://en.wikipedia.org/wiki/Citric_acid https://en.wikipedia.org/wiki/Crell%27s_Annalen 117 Trotter wrote a short journal article about the benefits of citric acid for treating scurvy: Trotter T. Dr. Trotter, on Citric Acid. Medical and Physical Journal. 1800;4:154-156. https://doi.org/10.5281/zenodo.10604544 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5670549 https://pubmed.ncbi.nlm.nih.gov/30490873 118 The process of swelling; a swollen structure July 6th. No bleeding from his gums since yesterday ; no other alteration to be perceived… Diet to-day ; bargou for breakfast, salt pork and pease for dinner, bread and cheese for supper. July 7th. Gums more florid ; hardness and tumefaction of the ham somewhat receded. Med. as yesterday. Diet ; bargou for breakfast, salt pork and pease for dinner, bread and cheese for supper. July 8th. Gums begin to assume a fine florid appearance ; they have not bled since he began the use of the salt, and are now beginning to adhere again to the teeth. Tumefaction in the ham considerably reduced ; dark livid colour p.394 almost gone ; he appears to be in much better spirits. Med. as before. Diet ; bargou for breakfast ; fresh beef and soup, with vegetables in it, for dinner ; drank some tea in the afternoon ; supper as before. July 9th. Knee more flexible, and all the other symptoms continue to mend. Med. as before. Diet ; breakfast and supper as usual ; fresh beef and soup for dinner. July 10th. A few small ulcerared points remain about his gums, but which are clean and of a healthy appearance. Med. u. a. Diet as before. July 11th. Symptoms disappearing fast. Med. u. a. Diet as mentioned before. July 12th. Gums in a perfectly sound state ; rigidity of ham almost gone, which is still a little thickened, but without any discoloration, pain, or even uneasiness ; has regained, his usual strength, and says, that he is in as good health as ever he was in his life, and fit for his duty as a topman ; to be convinced of which, I have just seen him run to the main top-mast head. He takes his medicine for this day, and to go to his duty to-morrow.” “REMARKS. The proportion of an ounce of the concrete salt of lemon to a pint of water, as used in this case, tastes stronger of the citric acid than the common lemon juice does ; it is much more agreeable and palatable, being without any of that musty taste which the lemon juice always acquires. On arriving in Cawsand-bay, this man had no money ; and, from all his messmates being in the p.395 same state of poverty, he has been totally deprived of any assistance from fruit or vegetables, except what he might have eat with the ship’s soup since the 8th instant. It will be observed, from the report of that day, what amendment had then taken place. Several of the scorbutics on board, with a milder disease, and who complained previous to this man, and who have regularly taken six ounces of lemon juice daily, continue now upon the sicklist, and will remain for some days yet to come. Such appear to be the antiscorbutic powers of the concrete salt of lemon ! THOMAS WATHERSTON, Surgeon, Superb.” 136 If ever a case of scurvy was delivered in an unvarnished tale, it is the present one. I directed Mr. Watherston to give eight ounces of the solution on the first day, and only six afterwards. When the disease is far advanced, as in this instance, there is a necessity of giving it a speedy check at once, which has been my constant practice. The result is certainly equal to any thing I ever observed from the recent fruit ; and I must remark, that thousands of common cases may be treated before a more decisive trial could be made. For my own part, I was perfectly satisfied, and gave the Admiralty that assurance in transmitting the original case to Mr. Nepean. At this time I was using my utmost endeavours to call the attention of the ruling powers to what I considered a valuable acquisition to the naval department ; and, with that view, sent a jar of the acid to Lord St. Vincent, informing him thereby of my trial, and the satisfactory result. The admiralty, in consequence, ordered other experiments to be made, by the direction of the Sick and Hurt Board. p.396 It now appeared, that the ingenious chemist had ; previous to all this, applied to the patronage of Earl Spencer for trials of his acid in the navy. That respected nobleman had given orders to that effect ; but how were they obeyed? The concrete salt was sent abroad to the West Indies and the Cape of Good Hope, climates where the disease is little known, and where the fruit is indigenous. This was literally sending coals to Newcastle ; and so it fared with the concrete salt.* * But the lemon juice itself was even sent in quantities to the West Indies, till an officer of great consideration called upon the surgeons of his squadron to know whether the juice sent from England was better than what could be purchased on the spot for one twentieth of the price. If any man was to bring coals from Wales, to work the steam-engines at Newcastle, what would you think of such a man? The Honourable R. A. Berkley had also ordered a trial to be made on board the Saturn, one of the advanced squadron off Brest, then under his command, where scurvy was frequent ; and two cases were selectd by Mr. Perry ; one of which took lemon juice, and the other the solution of concrete, of the same standard. Mr. Perry thought the preference due to the lemon juice in the cure, but I could not help thinking, that there were peculiarities in the case of the man that took the concrete, whom I examined, that fully accounted for the difference. Mr. Perry, at my request, tried another case with the [citric acid] crystals, and reports in the following terms. “The marine James Freeman, who first complained of scurvy on the 11th of August, the day you visited the Saturn, and for whose cure you gave me some of Coxwell’s concrete acid, was perfectly cured on the 24th of August. p.397 “According to your directions, I gave him eight ounces of the solution for the two first days, and six ounces a-day afterwards.” Mr. Lloyd of the Renown, the flag-ship of Sir John Warren, Bart. made several trials, and uniformly effected rapid cures, which made him speak of the medicine with the utmost confidence. Mr. R. Thompson of the Childers, a zealous and able young surgeon, in September 1800, thus mentions the crystallized acid. “I beg leave to observe, that I have made trial of the crystallized lemon juice [ie citric acid] (during a ten weeks cruize) you have been so condescending to recommend, and I have the pleasure to say, that I have found it answer all the purposes of the fresh fruit.” Mr. Scott of the Ajax, an experienced surgeon, gives similar evidence. Mr. Fleming of the Impetueux speaks favourably of it, but had not sufficient quantity to complete his cure. On board the Doris, trials were made by Mr. Adamson with what had been sent to the Ville de Paris by the Commissioners of Sick and Hurt, as ordered, from my application, by the Lords Commissioners of Admiralty. An equal number of patients, in symptoms nearly alike, were put on both acids for trial. For the three first days of their treatment, the whole had taken three oz. of lemon juice daily, besides an oz. as made into lemonade, which was now served by the purser, so that they might be said to have started tolerably fair. Mr. Adamson’s concluding remark is to the following effect. “According to the result of my observation, the concrete is an effectual and active remedy, and, I think, more certain and steady in its operation than the lemon juice, which, however, has been efficacious, and even specific, in the cure of the few complaints p.398 that have come under my observation. How long the use of either may be continued without injury to the 137 The pages are from the 3rd ed. (1799). https://archive.org/details/b2144092x/page/478/mode/2up p.62-63 Though there needs hardly any additional proof of the extraordinary efficacy of lemon juice in curing the scurvy, yet it may be of service to impress so useful a truth on the mind by mentioning such striking proofs of it as occurred from time to time. The Arrogant spoke with a Portuguese vessel near Madeira, from which some of this fruit was procured, and the only scorbutic man on board happening to have some of the most desperate symptoms, such as putrid gums, contracted hams, the calves of the leg hard and livid, and frequent faintings, a fair opportunity offered for trying its virtues. This man was allowed two of them daily, and was perfectly well in sixteen days, during all which time the ship was at sea, so that it was impossible to ascribe the cure to any other cause. p.479 CHAP. III. Of the Scurvy. I shall not be so minute, either in the description or treatment of the scurvy as of the preceding diseases. A detail of this kind would lead to unnecessary prolixity and repetition ; for the prevention and cure of it, consisting in diet rather than medicine, have been fully handled in the narrative part of this work ; and the subject, in the description, as well as the practical part, has in a manner been exhausted by Dr. Lind, whose treatise on this subject is more full, judicious, and satisfactory, than that of any other author ; and this work is more complete in all points, than any other work with which I am acquainted, upon any other medical subject. p.482 The scurvy generally begins to shew itself between the sixth and seventh week after men have been on sea victualling. The first visible symptom is generally sore gums, which are affected with a spungy swelling, and bleed upon the least touch, The next most obvious symptom is, livid blotches or wheals on the fleshy parts of the legs, under which hard caky substances are felt. This hardness increases and extends to other parts as the disease advances, and p.483 is considered as a mortal symptom when it reaches the trunk of the body. These symptom seems owing partly to coagulated masses of extravasated blood, partly to an error loci of the red globules, into the colourless order of vessels, where they stagnate. The face has a lurid bloated appearance, and the legs, near the ankles, become somewhat œdematous. The most remarkable symptoms next to these, is a lassitude and depression of spirits. A small degree of exercise produces laborious breathing. This, and pains of the thorax, are some of the most distressing symptoms in the advanced stages of the disease. Debility and lassitude increase as the disease advances ; and these, together with pains of the limbs, and contractions of the hams, confine the diseased person to bed ; and any rough motion, or an attempt to raise himself to the erect posture, is apt to bring on syncope. In the most advanced stages of the disease, they frequently expire on occasions of p.484 this kind, or in the act of carrying them on shore for cure, upon their arrival in port. In the same stage of it, the callus of broken limbs is dissolved or absorbed, so that the part comes to be in the state of a recent fracture. The appetite for food is in general unimpaired in every stage of this disease. The urine is scanty, and high coloured. When a part is bruised in any stage of this disease, and even before the disease shews itself by visible symptoms, there follows a tumour which is found to be filled with liquid blood ; and any wound, however small, especially in the lower extremities, is apt to fall into a foul ulcer, very difficult of cure. There is a great tendency to hæmorrhage, either spontaneous or upon the smallest injury. 144 The skin becomes dry and rough, indicating a want of perspiration. Besides the livid spots already mentioned, there are small specks, generally of a purple colour, very little raised above the surface of the skin. There are no cutaneous eruptions of the p.485 scabby, moist, or purulent kind, as in impetiginous affections, or what is sometimes called land scurvy ; and it is here proper to observe, that the sea scurvy, neither in its symptoms nor nature, has the least similitude or affinity to cutaneous affections, or any other complaints met with at land. There is a remarkable symptom sometimes attendant on this disease, which has escaped the notice of authors. This is the nyctalopia mentioned in Mr. Telford’s report.* * REMARKS [Telford’s report is on p.6-8:] During the course of last month we had one hundred and fourteen of the men, who contracted the scurvy in the late long cruise, recovered by the use of limes, which were procured at Montserrat. A pint of wine, with an equal quantity of water, made agreeable with sugar and tamarinds, is served to each patient daily. The regimen is exactly the same as mentioned last month. Since we came into port, very few have been seized with scurvy, but several complain daily of fluxes and feverish complaints, none of which seem at present to be of any consequence. Four patients have last month complained of an almost total blindness towards evening, accompanied with head-ach, vertigo, nausea, and a sense of weight about the precordia. The pupil is then extremely dilated, but contracts readily when a strong light is presented to it. Two of them had the scurvy in a high degree, one of them slightly, and the other seemed entirely free from it. I am not well acquainted with the nature or cure of this disease, which I believe is called Nyctalopia by some systematic writers. I gave those who were affected with it an emetic, which brought up a great deal of bile, and relieved the symptoms both of the head and stomach. This encouraged me to a repetition of it, which seemed also to be attended with benefit. I likewise applied blisters behind the ears, and gave bark and elixir of vitriol, with the antiscorbutic course, to those that required it. I can form no probable conjecture concerning the cause of this disease. I have observed a dilation of the pupil in scorbutic patients, and they complained of a cloud before their eyes, with imperfect vision, which disappeared as the scurvy went off. WILLIAM TELFORD. To Dr. Blane, Physician to the Fleet. It was also common in the garrison of Gibraltar, among those affected with the scurvy during the siege, as I was informed by Mr. Cairncross, surgeon to one of the battalions. It sometimes takes place in that incipient state of the disease, which does not shew itself by any visible symptom, but betrays itself, as mentioned above, by ecchymosis in case of bruises, or by scorbutic ulcers. But I shall not pursue the description of this disease into its minute symptoms and varieties, but refer the reader to Dr. Lind’s p.486 work, thinking it sufficient here to have enumerated such appearances as may convey a just idea of it, and enable one unacquainted with the disease to recognise it. The most striking appearances upon examining the bodies of those who die of it, are a tender state of the muscular fibres, which are easily broken or lacerated, large effusions of coagulated blood into the cellular membrane, an acrid fluid in the cavity of the thorax and abdomen, a separation of the cartilages and epiphysis from the bones, and an enlargement of the cavities of the heart. The sensible qualities of the blood are found but little different from what they are in healthy subjects. With regard to the prevention and cure, enough has been said in the preceding parts of this work, to prove that fresh vegetables and lemon juice are the only effectual antiscorbutics. I shall here mention a fact farther in proof of the effect of vegetables. When the fleet arrived at Barbadoes in May 1781, part of the soldiers, who served as marines, were affected with the scurvy ; and being sent to the army hospital, where p.487 at that time no fresh animal food was allowed, they recovered much faster by being confined to vegetable articles alone, than the seamen who were fed upon fresh animal food without any fresh vegetables. It has appeared that the juice of a particular class of fruit far surpasses every other remedy, whether dietetic or medicinal. It is difficult to decide under which of these heads it should be reckoned ; but its powers in both respects are so eminently and sin145 gularly efficacious, as not to be equalled by the virtues of any other remedy as yet known in any other disease. When the shortness of time also, as well as the certainty of its effects, and the small quantity in which it operates are considered, it comes nearer to the description of what is vulgarly called a charm, than any other medicinal article with which we are acquainted. p.488 It requires but few words to convey an idea of the great benefit derivable to the service from the proper application of this remedy. It must be obvious to every one, that whatever enables a ship of war to keep the sea double the time this could otherwise be done, as has been found to be the case this war (1799) both at home and abroad, must give a double efficiency to such a ship for the purposes of war, and must enable single ships and squadrons to prosecute certain services, to which they would otherwise be inadequate. A ship supplied with lemon juice, can keep the sea for four months with less detriment to the health of the men, than for two months without this article of refreshment. Besides the advantage of this upon long voyages, it is evident that in cruizes also, the benefits are incalculable, and too obvious to require being specified. It may also be remarked, that without this assistance to the health of mariners, war and commerce could not avail themselves of certain contrivances peculiar to this age, highly important to navigation, and honourable to human ingenuity. I allude to the lunar observations, and timepieces for ascertaining the longitude, wherep.489 by ships can prosecute a voyage of any length without making the land ; and, also to the sheathing in copper, whereby the necessity of frequent careening is superseded. Were it not for the resource of lemon juice, the health of men could not keep pace with these improvements ; for in former times, long and frequent stays in port were necessary for the health of the men, as well as the repairs of the ship. The introduction of this article may therefore be considered as an æra in the internal œconomy of our navy. It is, however a curious fact, though mortifying to human wisdom, and to our national sagacity, that the virtues of this remedy were equally well known in the beginning of last century as they are at this moment ; yet it has never till now attracted the attention either of medical men or of sea officers, to the degree it ought ; insomuch that it had, in a great measure, fallen into neglect, when the knowledge of it was revived, and its character retrieved, by the writings of the late Dr. James Lind, physician to Haslar hospital. 146 Gilbert Blane. Elements of Medical Logick (1819/1821/1825) Elements of medical logick : illustrated by practical proofs and examples ; including a statement of the evidence respecting the contagious nature of the yellow fever https://archive.org/details/b21515979/page/128/mode/2up (1st ed 1819; p.128-129) https://archive.org/details/b28037492/page/n229/mode/2up (2nd ed 1821; p.216-217) https://archive.org/details/b21305754/page/270/mode/2up (3rd ed 1825; p.271-272) p.270-272 (1825) SECTION VII. FIFTH SOURCE OF MEDICAL ERROR. THE AMBIGUITY OF LANGUAGE. Danger of being guided by the Name instead of the Nature of a Disease, exemplified in Sea Scurvy, the Yellow Fever, and Dropsy. p.271 The term scurvy, in the English language, and scorbutus in the general medical language of Europe, has been employed to denote, both cutaneous eruptions, and that disease which is caused most commonly by a long use of salt provisions, and principally known by its appearance in ships which have been long at sea. By having this name in common, these two diseases,122 though widely different, nay, without any thing in common in their characters, have been considered identical, and treated as such, particularly by a Dutch physician and author, named Eugalenus, in which he was followed by his countryman Boerhaave, and other authors, both British and continental. The consequence of this strange jumble was the adoption of a very vague, inefficient, and inconsistent practice, a practice also in the highest degree pernicious ; for it seems to have been mainly owing to the want of a clear conception of the diagnosis, and of the peculiar nature of the scurvy, that a simple, infallible, and readily procurable remedy for it, was long neglected, to the incalculable detriment of humanity, and the publick service. 122 Lind rejected the belief that there would be two scurvies: Land Scurvy and Sea-Scurvy. In Lind’s view there was only one scurvy so that the symptoms varied by the conditions. This is discussed in Lind’s Treatise in Chap. III. Of the distinction commonly made into a land and sea scurvy. Thus, although Blane largely followed Lind’s arguments, he maintained the belief in two different scurvies. p.272 Lemon and lime juice was well ascertained to be a certain preventive and cure of this dreadful malady very early in the 17th century; but the attention of Physicians having been absorbed in vain speculations, and their judgments perverted by the ambiguous import of the word, this excellent remedy was so much overlooked and neglected, that it was not rendered available to the best interests of mankind till after the middle of the 18th century. Had the expedition fitted out under Commodore Anson, in the year 1740, been provided with a few casks of lemon juice, none of those dreadful sufferings which make humanity shudder in perusing the narrative of that voyage, could have occurred. On account of the same most unfortunate misapplication of a word, Boerhaave recommended the use of Mercury in the sea-scurvy, because it is found to be a remedy in various cutaneous affections; and in conformity to this, it is related by Dr. Kramer, that some of the medical officers of the Imperial armies in Hungary, did, in the year 1720, subject to a mercurial course 400 men ill of the sea-scurvy, every one of whom died. Let no one therefore allege that the incorrect application of a single word is of small importance. 147 Gilbert Blane. Select dissertations on several subjects of medical science (1822/1833) https://archive.org/details/b21305316/page/4/mode/2up (1822; p.5-8) https://archive.org/details/b29332795_0001/page/20/mode/2up (1833; p.21-28) p.21 (1833) The scurvy, a disorder incident chiefly to a sea life, but by no means peculiar to it, has been eradicated by lemon juice, or more properly the citric acid;123 for the juice of the limes, Seville oranges, unripe China oranges, and in short of all the species of the botanical genus Citrus, or the natural order of fruits called Hesperidæi, possess the same virtue. The second Table was constructed principally with a view to elucidate the beneficial effects of the general supply of lemon juice. This was known to be a remedy for the scurvy far superior to all others two hundred years ago, as appears by the writings of Woodall.124 p.22 And does it not argue a most extraordinary blindness that this important fact should have been hardly known for more than a hundred years afterwards ; when the late Dr. Lind, of Haslar hospital, revived and diffused this valuable piece of knowledge by his writings. It was this author who first clearly stated the singular powers of this remedy in the cure of Scurvy, for Woodall only affirmed that its virtues were far superior to all other remedies. Notwitstanding this, the p.23 navy continued to suffer severely from this disease, till the order for a general supply of lemon juice. This salutary measure was accomplished by a representation from the Medical Board of the Navy in the year 1795, during the administration of Earl Spencer, from whose enlarged and benevolent mind every thing was to be expected. One of the most impressive parts of their argument was built on the report of the effects of it in the Suffolk, of 74 guns. This ship sailed from England on the second of April, 1794, and an 123 Trotter also believed that “citric acid” was the specific substance against scurvy. Trotter T. Dr. Trotter, on Citric Acid. Medical and Physical Journal. 1800;4:154-156. https://doi.org/10.5281/zenodo.10604544 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5670549 https://pubmed.ncbi.nlm.nih.gov/30490873 124 John Woodall. The Surgion’s Mate. 1617. [Scurvy: pp.177-202] https://doi.org/10.5281/zenodo.10651214 https://archive.org/details/b30331195/page/176 https://archive.org/details/surgionsmateortr00wood/page/176 experiment was made of supplying her with a quantity of lemon juice, sufficient to serve out two-thirds of a liquid ounce every day to every man on board. This was mixed with their grog, along with two ounces of sugar. The present p.24 regulation is one ounce of lemon juice and an ounce and a half of sugar. She was twenty-three weeks and one day on the passage, without having any communication with the land, and arrived in Madras Road on the 11th of September, without losing a man, with only fifteen men on the sick list, all slight cases, and none of them affected with the scurvy. This disease appeared in a few men in the course of the voyage, but soon vanished on an increased dose of lemon juice being administered. Let this fact be contrasted with the state of the Channel Fleet in 1780, as described by Dr. Lind (see Appendix, Illustration II. [find through the link above]) which was overrun with scurvy and fever, and unable to keep the sea after a cruise of ten weeks only ; and let the state of this fleet be again contrasted with that of the Channel fleet in 1800, already adverted to. It appears from the inspection of Table II. that during nine years of war preceding the general supply of lemon juice, the annual average of sick sent to hospitals was one in 3.9 of the whole men in the navy; but that in the nine succeeding years the proportion was one in 8.4. Other causes, particularly the improved methods by which fevers were diminished, contributed greatly to this decrease of sickness ; so that it may be difficult to assign precisely what is due to lemon juice. But what admits of no ambiguity, is that ever since the year 1796, scurvy has been unp.25 known in ships of war and naval hospitals. It is not even inserted as one of the heads of disease in the printed form of returns, see Table V and in Table IV there is only one case. One of the physicians of Haslar hospital has informed the Author that he has seen but one case of it there for the last seven years ; and one of the physicians to Plymouth hospital reports, that only two cases have occurred to him the last four years. It will be seen by comparing Table V which the 148 Author was favoured with by the physician to Plymouth hospital, with the like Table of Haslar hospital, at the interval of twenty-six years, what great changes there have been in that time in the number and quality of diseases, and particularly in the decrease of scurvy. It is found by the inspection of a great number of surgeon’s journals which I have made, that ever since the supply of this article, the scurvy has either not appeared at all, even on the longest voyages and cruises ; or if ever it did in a slight degree, it was soon made to vanish by an additional dose of lemon juice. It appears also from the same journals, to be favourable to health in other respects ; for some of the surgeons have given it as their opinion that it tends to diminish the number of fevers and ulcers. The latter are observed to be much connected with a scorbutic habit. It is true that there are instances of ulcers prevailing on board of ships in their most aggravated state since the p.26 introduction of lemon juice, but without any connection with scurvy. These were confined to particular ships and hospitals, in which infection had either been engendered, or communicated by intercourse, or even approach ; for a clean sore may be rendered a foul ulcer by the exhalations of the latter. The increased attention to separation, ventilation, and cleanliness, has since removed this evil, than which there was none more cruel to individuals, nor more embarrassing to the service. The latest account we have of the efficacy of this remedy since the first edition of this Work, is what occurred in the Fury and Hecla, ships sent to the Polar seas under the command of Captain Parry, on a voyage of discovery. They were twenty-seven months from England on this service, with no resources but what they carried with them. There is no instance in the history of navigation in which this has been effected without the appearance of scurvy, even for the fourth part of this time. It began to appear in the course of the voyage, but was immediately checked and subdued by increased doses of lemon juice. What is remarkable is, that it first shewed itself among the officers. It recurred in a few months, and attacked some of the sailors in both p.27 ships. It was then decided to return to England, this occurred at the island of Iglolich, in the Polar sea, in the year 1823, in N. lat. 69. The average temperature was -18.3, that is under zero. They were locked up in the ice from the 30th of October, 1822 till the 1st of August, 1823. Out of 118 men, of whom the crews of the two ships consisted, only three died in the whole course of the voyage. Those only who have made themselves acquainted with the early part of the naval history of this country, or those who have perused the interesting, popular and eloquent narrative of Commodore Anson’s voyage, in which the distresses and calamities, the dreadful sufferings and mortality arising from the sea scurvy, are depicted, can duly appreciate the value of this simple remedy. The power it possesses over this disease is peculiar and exclusive, when compared to all other alleged remedies. It is sui generis— Nil simile nec secundum—Its efficacy may also be stated as peculiar when compared to that of any other remedy in any other disease. It is a certainpreventive as well as cure ; no other remedy yet known can ward off this dreadful scourge of mariners, for an indefinite length of time under the use of salt provisions ; nor does it produce any bad effects on the constitution, like some other specifics in certain other maladies. It may therefore be affirmed with truth, that it performs p.28 not only what no other remedy will perform in this disease, but what no known remedy will effect in any known disease whatever.* * The Author has never seen the scurvy resist the citric acid,125 and in the perusal of several hundreds of surgeon’s journals, he has met with only two cases which seemed to resist it. 125 Here “citric acid” probably means acids of citrus fruit, and not the chemical substance “citric acid”. 149 Recent books on scurvy Carpenter KJ (1986) The History of Scurvy and Vitamin C This book is currently the most authoritative monograph about the search for the substance the deficiency of which causes scurvy. The book describes scurvy symptoms rather briefly. The reference section is extensive. https://www.cambridge.org/fi/academic/subjects/history/history-medicine/history-scurvy-and-vitamin-c https://archive.org/details/historyofscurvyv0000carp https://archive.org/details/historyofscurvyv0000carp_l0m0 Book reviews https://doi.org/10.1086/354301 https://doi.org/10.2307/204671 https://doi.org/10.1038/324177a0 https://doi.org/10.1086/ahr/92.4.927 https://doi.org/10.1093/jn/117.3.599 https://doi.org/10.3138/cbmh.4.2.198 https://doi.org/10.1093/jhmas/42.3.386 https://doi.org/10.1002/ajpa.1330770314 https://doi.org/10.1002/food.19880320246 https://doi.org/10.1017/S0007087400024602 https://doi.org/10.1177/027046769001000241 https://doi.org/10.1016/0191-6599(88)90148-9 https://doi.org/10.1001/jama.1987.03390130133051 https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc 1139720 https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc 1491777 https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc 2589114 https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc 5379445 150 Jonathan Lamb (2016) Scurvy: The Disease of Discovery. This is a well-written book about the social effects of scurvy by a historian. https://press.princeton.edu/books/hardcover/9780691147826/scurvy https://doi.org/10.23943/princeton/9780691182933.001.0001 Book reviews: https://doi.org/10.1086/699347 https://muse.jhu.edu/article/749046 https://muse.jhu.edu/article/682384 https://doi.org/10.1093/shm/hkx086 https://doi.org/10.1177/0265691417747183q https://doi.org/10.1017/S0007087417000954 https://doi.org/10.1080/1031461X.2018.1415609 https://www.jstor.org/stable/10.5401/healthhist.19.1.0118 https://worldhistoryconnected.press.uillinois.edu/14.3/br_ruediger.html https://slate.com/culture/2016/12/jonathan-lambs-history-of-scurvy-reviewed.html https://www.bsls.ac.uk/reviews/early-modern-and-enlightenment/jonathan-lamb-scurvy-thedisease-of-discovery https://www.australianbookreview.com.au/abr-online/archive/2017/201-april-2017-no390/3980-alan-atkinson-reviews-scurvy-the-disease-of-discovery-by-jonathan-lamb See also about the symptoms of scurvy: https://doi.org/10.1503/cmaj.160199 151 Stephen R. Bown (2003) Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail. This is intended for wide readerships. It gives a good overall view of scurvy. https://www.stephenrbown.net/scurvy-description.php https://archive.org/details/scurvyhowsurgeon00bown_0/mode/2up Book reviews: https://www.stephenrbown.net/scurvy-reviews.php https://doi.org/10.1080/00822884.2023.2233764 https://www.publishersweekly.com/9780312313913 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc535077 https://digital-commons.usnwc.edu/nwc-review/vol58/iss4/19 https://www.captaincooksociety.com/remembering-cook/books/book-reviews/scurvy-how-a-surgeon-amariner-and-a-gentleman-solved-the-greatest-medical-mystery-of-the-age-of-sail-bown-stephen-r-2003 152 David I Harvie (2002) Limeys: The True Story of One Man's War against Ignorance, the Establishment and the Deadly Scurvy. This is intended for wide readerships. It gives a good overall view of scurvy. However, the argument on “war against ignorance, the establishment” is not sound. That part is well discussed e.g. in Carpenter’s book. In academic circles, controversies about the causes and proper treatments of scurvy continued until the early part of the 20th century. For example, Elmer McCollum – one of the most influential nutrition researchers in the 20th century – was convinced that scurvy was caused by constipation.126 127 Sir Almroth Wright – famous immunologist – was convinced that scurvy was caused by blood being insufficiently alcaline.128 It was only in 1937, when Holt showed him that if scorbutic guinea-pigs were given pure crystalline ascorbic acid they were cured of experimental scurvy and this substance could prevent the condition, that Wright capitulated.129 130 Therefore, it is unreasonable to accuse the establishment of the late 18th century for making decisions on the basis of best information then available. Otherwise the book is interesting. https://www.thehistorypress.co.uk/publication/limeys/9780750939935 Book reviews: https://muse.jhu.edu/article/40931 https://muse.jhu.edu/article/172580 https://www.jstor.org/stable/44448080 https://doi.org/10.1353/bhm.2004.0125 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1124350 https://www.captaincooksociety.com/remembering-cook/books/book-reviews/limeys-the-true-story-ofone-man-s-war-against-ignorance-the-establishment-and-the-deadly-scurvy-harvie-david-i-2002 126 McCollum EV (1917) https://doi.org/10.1016/S0021-9258(18)86722-9 127 McCollum EV (1918), p. 937-940. https://doi.org/10.1001/jama.1918.02600380001001 128 Wright AE (1900) https://doi.org/10.1016/S0140-6736(01)99819-8 129 Lewis HE (1972) https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1644345 130 Holt LB (1972) https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1644320 153