James Lind at Haslar Hospital 1758–1774: a methodological theorist

James Lind is remembered principally for his controlled trial comparing different treatments for scurvy, reported in 1753, which he did during active service as a ship’s surgeon in the Channel Fleet. ¹ In 1758, he was appointed Physician-in-Chief of the Royal Naval Hospital at Haslar, near Portsmouth, and remained there until he retired in 1783. ² Although there are no reports of further clinical experiments that were as clearly conceptualised and described as his controlled trial of treatments for scurvy, Lind’s writings while at Haslar throw further light on his approaches to research.

At that time, the Royal Naval Hospital was one of Europe’s largest institutions for the treatment of acute diseases: it had 1000 beds when Lind took over and 2000 beds by the time he retired. In contrast to his colleagues at the great metropolitan hospitals, Lind was employed full-time rather than as a consultant, as were more than a dozen assistant surgeons and apothecaries. According to his own testimony, he saw thousands of patients suffering from the two most ravaging afflictions of his time, scurvy and ‘fevers’.

It may be helpful in conceptualising the problems posed by ‘fevers’ in the 18th century to think of them in terms of the problems posed by ‘cancers’ today. They are major killers. Although a great deal is known about them, there continue to be fundamental disputes about their nature and treatment: How many kinds are there? Just how, in essence, does one kind differ from another? How should they be classified? What are their causes? And so on. These were the questions that 18th-century doctors asked about ‘fevers’. And despite a huge mass of relevant partial truths, many contemporaries recognised that their ignorance, like ours about cancers, was enormous. They saw the problem as complex and confused.

Lind was at Haslar at a time when methodological questions in medicine were eagerly debated, particularly in Britain.^3,4 Although he was above all a practical man with a duty to perform, scattered in his writings after 1758 we find a number of methodological statements revealing his thinking about his research programme. His little known publication entitled Two papers on fevers and infection (Lind ⁵ and second edition ⁶ ) contains good examples of these methodological statements, and that is why it has been included in the James Lind Library.

Lind stressed the primacy of ‘facts’ (his own, testified observations) over much maligned theories. Had not his own observations led him, 10 years earlier, to remove ‘a great deal of rubbish’ before he could finally see the subject of scurvy ‘in a clear and proper light’ (Lind, ¹ p. viii)? Now ‘a very extensive practice in fevers … in one of the first hospitals in Europe’, qualified and justified his ‘making researches into the dark and abstruse subject of infection’ (Lind, ⁵ pp. 1–2). He required not simply observation, but numerous observations, for ‘knowledge in physic can only be attained by a series of observations’ (Lind, ⁵ p. 79 and Lind, ⁶ p. 268). Such a quantitative approach would help to distinguish ‘symptoms merely accidental … from the constant and essential sign of the disease’ (Lind, ⁶ p. 270).

A quantitative strategy was equally crucial for assessing therapy. ‘I have often thought’, Lind insisted, ‘that publishing only one or two singular or particular cases, does more harm than good’. Furthermore, it was clear to him that ‘the best proof of the efficacy of any method, is the success with which it is attended’, rather than its theoretical basis, and it was important to him that it was publicly verifiable by being based on analyses of hospital records, and stated numerically. These principles held true for his epidemiological conclusions and hygienic recommendations, including special fever wards designed to prevent the spread of a contagious disease (Lind, ⁵ pp. 70–73).

Lind also used the notion of comparing the course of disease following medical treatment with its natural course, in various times and regions and as reported by various authors. He postulated a one volume ‘synopsis of the writings on fevers, in a chronological series’ comprising perhaps ‘an abridgment of the works of above two hundred authors, whose observations would deserve a place in it’, as he had actually done for scurvy (Lind, ¹ pp. 341–451). He set out inclusion criteria for what we would today call a systematic review: ‘Disengaged from conjecture, naked truths should only appear, as are confirmed by observations and facts’. In this way, ‘the influence of a favourite opinion, or of a pre-conceived fancy on the writings of some, even of our best instructors, such as Sydenham …, would more clearly be perceived’ (Lind, ⁵ pp. 79–80).

Lind realised the limits of the information obtained in this systematic way, for example, by drawing attention to the role of the patient’s mental disposition in the healing process (Lind, ⁵ pp. 85–86). However, although he recognised that information might not apply in a particular situation because of ‘idiosyncrasy’ (Lind, ⁵ p. 72), he did not make the mistake of believing that all treatment could be individualised, stating in the third edition of his Treatise of the Scurvy ⁷ that deviation from the ‘generally proven rules’ was allowed only when these had failed (p 535).

Lind’s Two papers on fevers and infection also illustrate his approach to the development of the theory of fevers, albeit making clear to his readers the speculative nature of inferences based on ‘laboratory experiments’. For example, he compared the distribution of the three layers of clotted blood (the serum, the ‘buffy coat’ and the red cells) in samples taken from healthy men and women and from various categories of patients, speculating that the differences he found reflected the ‘inflammatory nature’ of a disease (Lind, ⁵ pp. 97–106). Later, instead of classifying fevers on the basis of differences in their symptoms, he used autopsies to classify them according to the organ(s) that appeared to be damaged. And he used statistical returns from Haslar and from ships active across the world to document the epidemiology and correlates of fevers (crowding, dirt, semi-starvation), and the contagious nature of jail-fevers, hospital-fevers and ship-fevers, showing that they were actually identical (Lind, ⁵ pp. 1–2, 4–5, 7–11, 26, 34, 40–41, 58, postscript).

In brief, as a researcher, Lind was not only a clinical observer and experimentalist, but also a nosologist, pathologist, laboratory researcher and epidemiologist.