Sm. Sci. Med. Vol. 33. No. 4, pp. 347-353, 1991 0277-9536191 S3.00 + 0.

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Printed in Great Britain. All rights reserved Copyright Q 1991 Pergamon Press plc

SCURVY LINDS MEDICAL GEOGRAPHY

FRANK A. BARRETT
Atkinson College, York University, 4700 Keele St Toronto, Ontario, Canada M3J lP3

Abstract-The name James Lind is not one usually associated with medical geography. Yet Linds book,
An Essay on the Incidence of Diseases in Hot Climates, written in 1768, is of great importance in the
development of medical geography. When Finke wrote his medical geography a quarter of a century later
he quoted extensively from Lind.

Key words-history and development of medical geography

Since the location of the Fourth International Sym- third work, the one which Garrison has classified as
posium in Medical Geography is in the United King- tropical medicine, and Singer and Underwood as
dom, it is appropriate to consider early British opened the campaign for the conquest of the trop-
contributions to the development of medical geogra- ics, and Curtin describes as, the most authoritative
phy. In the literature, aside from John Snows im- survey of British tropical medicine, that is the focus
portant application of geographical methods, there of this paper [6, p. 362, 7, p. 186, 81.
are few well-known historical references to British The essay, containing 342 pages of text plus 24
authors. For example, in Barkhuus useful review on more pages of additions, corrections and indices, was
the history of the development of medical geography, written when Lind was in his early fifties. By this time
he cites only three British sources that were written he had had nearly 30 years of medical experience, and
before the late eighteen hundreds [ 11. Less frequently was personally familiar with some of the geographical
cited is Howes historical review which forms part of diversities of the world having served in the Mediter-
the introduction to his National Atlas of Disease ranean, the West Coast of Africa, and the West
Mortality in the United Kingdom [2]. The historical Indies. Lind states in the introduction that this work
introduction appears to be largely based on is I. . . a conclusion of all the considerations which I
Barkhuuss work, but in addition, Howe does pay formally offered . . ., and was written in the hope of
attention to British sources not included in the providing information about disease conditions in
Barkhuus review [2, pp. 7-161. distant lands for the thousands who left England each
In spite of Howes contribution, when one dis- year to serve in the colonies [S, pp. l-21. While the
cusses the pioneers of modern medical geography, it objective of his first two treatises were to improve the
is the German and the French, and not the British health conditions of those at sea, the third works
authors that come to mind [3]. Therefore, it was with focus was to help preserve their health on land while
great interest that while working at the library of the residing overseas.
Wellcome Institute for the History of Medicine, I It is the organization and the underlying rationale
noticed in the chronological catalogue a 1768 refer- used in the An Essay on Diseases Incidental to Eu-
ence to a book titled An Essay on Diseases Incidental ropeans in Hot Climates that is of interest to medical
to Europeans in Hot Climates [4, 51. geographers, and physicians interested in geographi-
The author, James Lind (17161794), was a native cal medicine. The book is divided into three parts.
of Scotland and is popularly remembered today for The first part, Diseases incidental to strangers in
his work on scurvy. Lind became a surgeon, which at different parts of the world is clearly medical geogra-
that time was a much lower position than a physician, phy, although Lind doesnt use that specific term. He
and served with the Royal Navy from 1739 to 1748. divides the world into the four regions; Europe and
During this period he continued to study medicine North America, Africa, the East Indies, and the West
and in 1748 he graduated as a physician from the Indies. A chapter is assigned to each of these regions.
University of Edinburgh. For the next 10 years he left In turn, the chapters are sub-divided mainly into
the Navy and had a private practice in Edinburgh geographical sub-areas. The second part is untitled,
where he was also the secretary to the Royal College but again has a strong geographical focus, albeit this
of Physicians. He returned to the Navy in 1758 to the time in a systematic rather than a regional sense. Its
important post of senior physician to the Royal chapters give advice on: the preservation of health for
Naval Hospital at Haslar located in Gosport. His those who reside near the sea in hot climates; the role
fame is based on three epoch-making treatises: A of air on health; and advice to those who are located
Treatise on the Scurcy (1753); An Essay on the Most inland. The third part, also untitled, is predominantly
Effectual Means of Preserving the Health of Seamen medical rather than geographical, and suggests cures
(1757) and An Essay on Diseases Incidental to Euro- for the various illnesses.
pean in Hot Climates (1768). The first two works were What is particularly appealing in Linds writing is
published while Lind was in private practice, his demonstration of critical reasoning. For example,
although they were based on his experience and before analyzing his four-fold division of the world he
observations while in the Navy. However, it is his writes an introduction in which he reveals the
348 FRANK A. BARRETT
geographical orientation of his thought-process. He
makes the observation that:
Men who thus exchange their native for a distant climate,
may be considered as affected in a manner somewhat
analogous to that of plants, removed into a foreign soil;
where the utmost care and attention are required, to keep
them in health, and inure them to their new situation; since,
thus transplanted some change and alteration must happen
in the constitutions of both.
Some climates are healthy and salutary to European
constitutions; as some soils are favourable to the production
of European plants. But the countries beyond the limits of
Europe which are chiefly frequented by Europeans, are very
unhealthy, and the climate often proves fatal to them [5,
pp. 2-31.
Still in the introduction, he illustrates this point by
examining the experience of the Portuguese in the
15th and 16th centuries as they explored the coasts of
Guinea and of India. Lind notes that even though
they were sailing in uncharted waters they suffered
less from shipwrecks than they did from sickness. In
fact, the death toll from sickness was greater than
shipwrecks, fighting with the natives, and all other
accidents combined. Further, he adds that many
places on the coast which formally were settled have
hardly a trace remaining of their presence.
The Portuguese explanation for the sickness they
experienced was the diet they consumed in the new
land. However, they noted that such as had the good
fortune to escape sickness soon after their arrival
could afterwards enjoy a pretty good state of health.
From this observation they concluded that the blood
of such lucky persons had been entirely changed by
the diet of the country. Lind notes that this expla-
nation had disastrous consequences since they started
the practice of bleeding newcomers, if they became ill
shortly after their arrival in the colony. This practice
which instead of accelerating their adaptation to the
climate, only reduced the patient to a state of weak-
ness. Linds awareness of geographical similarities
and differences and his ability to think critically led
him to conclude that local food consumption could
not be the cause of sickness in such climates. Firstly,
because rice, millet, Indian corn, and other foodstuffs
eaten in the most unhealthy places could be safely
eaten when brought to other places. Secondly, if the
Europeans ate only European products in their diets
this still did not prevent them from getting sick in
those climates. Also, he notes that the drinking of bad
water had been given much of the blame for sickness
but states that while unwholesome water would pro-
duce fluxes and some other diseases, that this could
not be the sole cause of sickness since the occurrence
would be uniform at all seasons of the year which was
not the case. Another common explanation for the
high rate of death amongst the newly arrived was the
debauchery of these young Europeans, but Lind
observes that the most abstentious and temperate of
individuals also had high death rates in unhealthy
countries [S, pp. 3-8).
At the time Lind was writing, he indicated that the
number of English being sacrificed to hot climates
was hardly credible and could only be guessed, but as
an indication he cites the case of Jamaica where the
equivalent of the whole of its white population was
buried every 5 years! He says that it is the fevers and
the fluxes that are the cause of 19 out of every 20
deaths in Jamaica and continues by stating that these
are the prevailing and fatal maladies in unhealthy
countries in all parts of the world [5, pp. 9-101.
Lind concludes the introduction calling for a clar-
ification of terms. By fevers he means the three
symptomatic conditions which physicians had his-
torically classified as; intermitting fevers, in which the
patient is free of all symptoms of the fever during its
absence or intermission; remitting fever, where the
fever has irregular or imperfect intermissions, and a
continual fever where there was no perceptible inter-
mission [5, p. 151. The term fluxes was a reference to
dysentery, the term being a derivation of the Latin
fluxus meaning an excessive flow or discharge. There-
fore, as was the norm at this time, both terms had a
descriptive rather than a causal meaning.
What is of particular interest to medical geogra-
phers about this book is that Lind, the physician,
demonstrates such a strong geographical orientation
in his writing. Of the first 271 pages, which form the
body of the text, Lind devotes 125 pages to Part I,
which regionally covers diseases travellers will en-
counter in different parts of the world, and 88 pages
to Part II, which systematically covers the role of
location on diseases. As noted already, this first part
is a global medical geography in which the then
known world is divided into four major regions with
the major regions being further divided into sub-
regions. Lind is aware that there is a geography of
disease and the basic problem he sets for himself is
trying to understand why diseases occur in some
places and not in other places. It is clear that Lind is
using the geographical device of the region to analyze
disease. Of course as a physician, he is fundamentally
interested in solving, or at least alleviating disease
problems, but in this study his main method is to
think geographically and apply concepts such as site,
location, variance of places, and regions in attempt-
ing to resolve the basic problem. Thus his geographi-
cal thinking goes much deeper than a simplistic
regional classification. He is fundamentally struck by
the significance of location and the character of place
in trying to understand the nature of disease.
Although the focus of the book is on the diseases
that Europeans will encounter in the tropics, in his
opening regional analysis he examines Europe and
North America. He does not clearly state why he does
this but infers three things: (1) that in line with his
geographical approach he is taking a global perspec-
tive; (2) that non-tropical areas have different types of
disease profiles as noted in his examples from
Canada; and (3) that the agues and fevers found in
Europe and North America may be the same or
similar diseases to those found in the tropics.
Because Lind lived at a time before the microbio-
logical revolution and thus never knew the true cause
of the fevers and fluxes that he treated, we make the
error of underestimating the powers of observation
and critical thinking of his and other brilliant minds
like his. For example he wonders:
There are many difficulties which occur in assigning a
satisfactory reason, why in some countries, as in those
between the tropics, heavy and continual rains should
produce sickness, while in other places, especially in the
southern parts of Europe, a want of rain for two or three
 Scurvy Linds medical geography
months in summer brings on diseases almost similar
[5, P. 461.
Indeed this was a problem confronting thinkers. It
leads to the further confounding problem of the same
disease being given different names in different
regions.
With regards to diseases in West Africa, Linds
enquiring mind about the nature of the differentiation
of places is demonstrated by the fact that he had
samples of waters from Senegal, Gambia, and Sierra
Leone, sealed in bottles and sent to him. But on
uncorking them he states that: I could not, however,
discover, by the help of a good microscope, the least
appearances of any animalcules; nor did any
chymical experiment discover uncommon contents or
impurities in those waters [S, p. 5711.
His concern about the similarity of diseases and the
differences of places lead him to conclude that:
As far as I have been able to learn, there is a pretty exact
uniformity in the appearances and nature of the fevers and
fluxes which afflict strangers in Guinea: with this difference
only, that their malignity or violence, together with the
mortality proceeding from them in the rainy season, are in
proportion to the situation of the place, and its free
ventilation by wholesome air.
The natives themselves are not exempted from those
diseases. They are in general short lived, and perceive as
various degrees of purity and insalubrity of the air in
different spots of their country, as are felt in Europe or in
any other part of the world [5, p. 591.
His acute observations about the nature of location
lead him to a different conclusion about the healthi-
ness of the tropics than many of his contemporaries.
Lind says that:
All tropical countries have, properly speaking, only two
seasons, the wet and dry; the former being commonly of
about four months continuance, and the season of sickness;
whereas, for many months in the dry season, most parts of
this country [the Guinea coast] are equally healthy and
pleasant with any in the world.
and,
In such an uncultivated, swampy country as Guinea, one
would hardly expect to hear of a season of health; but what
I have asserted is an experienced fact, with respect to newly
arrived Europeans. For notwithstanding such as constantly
reside there retain, through all the seasons of the year,
evident marks of the insalubrity of the climate, yet the
indisposition under which they labour in the dry months, are
generally the remains of former illness, or the consequences
of what their constitutions had suffered during the sickly
season [S, p. 46).
The idea that the whole of a region was unhealthy,
or that unhealthy locations were dangerous through-
out the year were popular concepts which Lind
challenged. He believed that health-wise, dangerous
places were site-specific and season-specific. Although
his explanation for fevers falls under the category of
miasmatic theory, Lind makes many astute obser-
vations. In the beginning of the regional analysis in
the first part of chapter one, he identifies what he
thinks are the causative factors of fevers. He says that
the severe disease episode of 1765-66 which occurred
in many parts of England was due to a combination
of factors. These factors included, a change in direc-
tion of the prevailing winds which then blew over
349
areas of water, mud, marshes, or damp places.
Another factor was a very hot summer. He observes
that the more excessive the heat the more violent and
extensive the disease. In addition he notes that the
attacks were more severe in people who were
strangers in a given area [5, p. 461. Lind compares his
observations for England with that of a report from
Zealand region of the Low Countries. This report,
based on 28 years of medical practice by a Dr Wind,
supports Linds observations and adds that the
poorly housed and fed, in particular indigent
foreigners, are more prone to experience severe at-
tacks, and that the disease is checked by colder
weather. Dr Wind further speculates that these
diseases are the same as the double tertian fevers,
common between the tropics [5, pp. 28-301.
Lind gives several examples from different regions
of the world to demonstrate that slight differences
location could have great differences in both morbid-
ity and mortality [5, pp. 32, 38, 71, 761. He particu-
larly notes that with the change in prevailing winds
and the onset of rains, in certain locations the soil
seemed to begin to ferment creating, to use his term,
a noisome vapour [5, pp. 48-491. From his use of this
term noisome, he appears to be using its second
meanmg i.e., injurious, rather than bothersome,
which is more commonly attributed to the word
today.
He chides those in charge of selecting locations for
tropical posts, with being so unaware of the charac-
teristics of the sites that they select very unhealthy
places. He says:
It is not uncommon, in many trading factories, to meet with
a few Europeans, pent up in a small spot of low, damp
ground, so entirely surrounded with thick woods, that they
can scarcely have the benefit of walking a few hundred
yards, and where there is not so much as an avenue cut
through any part of these noxious woods for the admission
of wholesome and refreshing breezes. The Europeans have
also unfortunately fixed some of their principal settlements
either on low, inland, unperflated [unventilated] and uncul-
tivated spots, the foul banks of rivers, or near their swampy
and oozy mouths, or upon salt marshes, formed by the
overflowing of the ocean; and in many places the putrid fish,
scattered on the shore by the Negroes, emit such noisome
effluvia, as prove very injurious to the constitution [5, p. 511.
He returns to this criticism in the chapter on the
East Indies when he attacks Dutch officials by saying:
Upon this occasion we cannot help remarking, that a daily
and familiar observation of the fatal errors and mistakes
committed by the young, thoughtless and ignorant, does not
much excite our wonder; but we are apt to be struck with
astonishment, when we find that the founders of great
towns, and the governors of extensive provinces, through
ignorance or mistakes, have exposed populous and magniti-
cent cities to an annual and pestilential destruction. This
seems to be the, case at Batavia; where the Dutch, in
endeavouring to make this their capital in India [East
Indies], to resemble their cities in Europe, have adorned it
with canals or ditches intersecting each other, and running
through every part of it. Those canal, replete with water,
may perhaps serve for some use, or rather for ornament; but
notwithstanding the utmost care to keep them clean, in the
hot and unwholesome climate of Java, during and after the
rainy season, they become extremely noxious to the inhabi-
tants, but more particularly to strangers. The unwholesome
air of that place alone has cut off more Europeans than have
350 FRANK A. Bw
fallen by the sword, in all the bloody wars carried on by the
Dutch in that part of the world [5, pp. 44451.
With the benefit of historical hindsight one can
appreciate how valid Linds observation and specu-
lations were. However, he was not critical about all
tropical development. To the contrary, a purpose of
writing the book was to emphasize the possibilities of
Europeans living in the tropics provided that geo-
graphical factors, as they affected health, were taken
into consideration. He says:
Notwithstanding what has been said, I think it will hardly
admit of doubt, that if any tract of land in Guinea was as
well improved as the island of Barbadoes, and as perfectly
freed from trees, shrubs, marshes, etc., the air would be
rendered equally healthful there, as in that pleasant West
Indian island [5, pp. 51-521.
Also, he notes that close by locations of high
morbidity there are usually locations that prove
valuable as places of recuperation. He cites as
examples of these the island health stations of the
Canaries, and St Helena. Regarding the Canaries he
comments:
That the Canaries are blessed with a temperate, pure, and
wholesome air. No sooner were the English officers landed
there, when brought sick from Senegal, than they found an
immediate and satisfactory alteration in their health.
There they no longer felt the scorching heat of a meridian
sun, tempered with no refreshing breezes, and no cool air;
from which impenetrable surrounding woods had before
debarred them. They were no longer sensible of the sudden
and piercing chillness of the evenings, nor tortured
with swarms of blood-sucking gnats and flies. It was
indeed surprising in how short a time they recovered
their health, strength and colour, in those delightful islands
[5, pp. 71-721.
However, Lind points out that all islands are not
so blessed. On Cape Verde strangers are not exempt
from sickness during the rainy season, and in still
others, such as Fernando PO, Sao Tome, and
Principt, sickness there was severe [5, p. 721.
One of the points he makes repeatedly is that it is
the newcomer who is most susceptible to attacks of
fevers and fluxes and that after a period of acclimat-
ization their prospects for experiencing relative health
in hot climates improves. To his credit he realizes that
this is not a phenomenon restricted to Europeans. He
notes that when the Blacks were taken back to
Lisbon, as strangers in a different climate, they too
suffered from many diseases [5, p. 661. Even more to
his credit he observes that even people moving from
one tropical region to another tropical region are at
great risk. In support of this claim he cites the
Chinese merchants from Manilla who after the
Spanish acquired the Philippines, moved to India.
Lind says, . . . but the air of this country proved so
fatal, that most of the Chinese and their families died
soon after their arrival [5, p. 781. Lastly, with respect
to acclimatization, he notes that one group will have
particular difficulties, those who have had obstinate
agues in England and Holland, almost constantly
suffer a relapse when they come on this coast
[Guinea] [5, p. 711.
The question arises, since Lind took a global and
comparative view of disease, did he suspect that some
diseases might be diffused over large geographical
areas? As previously noted he cites Dr Winds
suspicion that the tertian fever of Holland was the
same disease as those of the East Indies. Lind was
suspicious that the Yellow Fever of the West Indies
was similar to cases reported in Cadiz and the East
Indies. But in discussing the assertion by some that
Yellow Fever was carried to the West Indies by a ship
sailing from Siam, he says that this is an opinion
truly chimerical [absurd] [5, p. 1131. It is not clear in
the text whether he is objecting to the specific claim,
or to the principle of the diffusion of disease,
although the force of his statement suggests the latter.
In concluding Part I he asks three practical ques-
tions.
1. What are the signs of an unhealthy country?
2. What types of employment in hot countries
are fatal to Europeans?
3. How can persons in these areas reduce their
chances of becoming sick?
To the first question Lind says:
The first proof of an unhealthy country which I shall
mention, is a sudden and great alteration in the air, from
intolerable heat to a chilling cold. This is perceived as soon
as the sun is set, and for the most part is accompanied with
a very heavy dew, and shows an unhealthy, swampy soil; the
nature of which is such, that no sooner the sun-beams are
withdrawn, than the vapour emitted from it renders the air
raw, damp and chilling, in the most sultry climates; so that
even under the equator, in some unhealthy places, the night
air is very cold, io an European constitution.
The second is. thick noisome foas. arising chiefly after
sun-set, from thk vallies and mar; particul&ly from the
mud, slime, and other impurities. In hot countries, the scent
of these fogs may be compared to that of a new cleaned
ditch.-Diseases therefore arising from these causes, do
generally take place in the night, or before sun-rising.
The third is, numerous swarms of flies, gnats, and other
insects, which attend putrid air, and unhealthy places cov-
ered with woods [5, pp. 127-1281.
To these above three signs Lind concludes by
alerting people to two other tell-tale signs. He advises
avoiding areas where a butchers meat is soon cor-
rupted and becomes full of maggots within a few
hours, and where there is a certain type of sandy soil
from which pestiferous vapours arise.
As to the most unhealthy types of employment for
Europeans Lind identifies clearing vegetation and
cutting down woods; being in open boats after sunset
where the soil is swampy or where there are great
night fogs; and fetching freshly killed meat at night.
Lind claims that this latter practice of getting meat
for the companies on board ships has lead to the
death of several thousand seamen annually [5, p. 1341.
His solution to the problems of unhealthy
locations, and employment is as follows:
The best preservation against the mischievous impressions
of putrid fog, a swampy, or of a marshy exhalation, is a
close, sheltered and covered place; such as the lower apart-
ments in a ship, or a house in which there are no doors or
windows facing the swamps. If, in such places, a fire be kept
either at the doors, or at other inlets into a house, (as is
practiced in some unhealthy countries, during the rainy or
noisome foggy season) or in the hatchways of a ship, these
fires, together with the smoke, prove an excellent and
effectual protection to those within against the injuries of a
bad air [5, p. 1361.
 Scurvy Linds medical geography
In a truly scientific manner, Lind goes on to explain
that these recommendations are based in part on the
observations of two vessels anchored side by side in
1765 on the Guinea coast, the one, a ship of war, in
which no smoke from the fire-place came between her
decks and the other, a sloop of war, in which the
smoke from the cook-room spread itself all over the
ship and in particular over those parts where the men
lay. In the smoke-free ship, many men were very
sickly and many died. In the smoky sloop few were
taken ill and none died [5, p. 1371.
Lind concludes this part of his book by saying that
to send unseasoned Europeans into the mouths of
rivers and further upstream during the rainy season
where there is no shelter from pestiferous nocturnal
air is inexcusable [S, p. 1391.
In Part II of his book Lind leaves his regional
analysis and focuses on the principles he has outlined
in Part I with respect to the role of site, location, and
the characteristics of place. He says:
The observations which we have made concerning the
various climates in the four grand divisions of the world,
point out those diseases which are most fatal to Europeans
in different countries abroad.
It now remains to deduce some useful conclusions from
these observations [5, p. 145-1461.
Section one of Part II is a synopsis of the suspected
influence of geographical factors. His first obser-
vation is that the diseases strangers encounter in the
different climates, appear to be similar to each other
and the variance in their violence* depends largely on
the conditions of heat, moisture and in particular on
the nature of the soil and of the winds [5, p. 1461. He
notes that once acclimatized, Europeans living over-
seas have relatively healthy lives to such a degree that
many decide to remain overseas rather than endure
the rigours of re-acclimatizing themselves to con-
ditions in their former European homeland. He re-
emphasizes points made in Part I such as: no place
seems to lack at least a relatively healthier season; the
most unhealthy places have healthier spots nearby;
fatal diseases seem to be confined to a particular
Season and during this season to specific places.
Therefore, strangers should always leave unhealthy
spots during the sickly season. Lind wonders why
people dont see this obvious solution about
unhealthy places [S, pp. 1461481.
In Part II Lind takes a systematic rather than
a regional geographical perspective by dividing it
into two chapters: Advice for the preservation of
Europeans, who reside near the sea in hot climates;
and Advice for the preservation of such Europeans
as reside in inland countries. The first point he makes
is that there is a variation in the location of diseases,
so that while at first sight it might appear almost
impractical to find both a safe and convenient retreat,
all places in an unhealthy region are not equally
unhealthy. Lind supports this basic geographical fact
by citing examples from Africa, England, and Europe
[5, pp. 149-1551. Also, he notes that even in the
shifting of an anchorage by half a league that a
significant decrease in mortality occurred [5, p. 1561.
He suggests that in the most unhealthy locations that
a ship or a floating factory be established as a safer
haven for the Europeans.
351
In an example of geographical medicine rather
than medical geography Lind ponders [9]:
First, we are to consider the effects of the impure air of hot
countries, during the rainy seasons, on the human body,
when in health. And here it is remarkable, that the breast
and lungs, as also the throat, through which it passes, are
generally the parts of the body which suffer the least, though
in constant and immediate contact with it.
The parts chiefly affected by an impure air, in a hot
climate, are the brain and stomach, or in other words, the
nervous system, and the organs of the alimentary digestion
(5, p. 1701.
This is another example of Linds perceptive mind
to see the contradiction between the assumed cause
and the observed result.
Lind returns to his medical geographical focus and
observes that since. Europeans in inland locations
cannot receive the protection of floating factories that
their safest location would be on the side of a hill or
mountain, provided that it was located at least 3 miles
from a morass, i.e. a tract of low-lying, soft, wet
ground [5, pp. 198-1991. Here again Lind returns to
the theme that an asylum for health can be found in
almost any quarter of the globe. He continues over
the next several pages giving specific examples to
support his assertion. Basically, what Lind is advising
is: dont change the remedy/medicine, change the
location. His solution is geographical and this is why
his book is fundamentally medical geography. In
example after example he gives a geographical per-
spective. He is convinced that if the geography of
place A is different than the geography of place B
then the disease profile will be different.
It is worth noting that in the final pages of Part II
that Lind also gives micro-regional case studies,
examines some factors of hospital locations, and
considers the role of diet in the health of people in
different locations. In this he is following the basic
trilogy of medical geography: disease, medical care,
and nutrition.
As well, he shows that he is a liberal thinker and
scorns racist arguments. Already we have cited his
observation that Africans travelling to Europe would
suffer sickness because they were not acclimatized to
that region. Later in the essay he rejects the common
opinion, that those people who sleep on shores in
such places [Guinea] are poisoned by the negroes, is
so foolish and ridiculous, that it hardly deserves
notice [5, p. 2191. With regard to the unhealthiest
locations, he suggests training the local acclimatized
population for employment where it is especially
unhealthy for Europeans. In answer to the common
belief that the local population could not be trusted
he points out the Portuguese example and says:
At Benguela, Catcheou, and other unhealthy places of
Guinea, few Portuguese of the white colour are to be met
with, except priests, and such as are banished to that quarter
of the world. The Portuguese have so instructed and civi-
lized many of the blacks and mulattoes in their African
settlements, that besides priests of a dark complexion, who
are often men of letters, well versed in the Latin, Greek and
French languages, they have their principal factors, and
many rich merchants, lawyers, surgeons, and others of the
same colours: all of these prove as faithful, and good
subjects to the crown of Portugal as any in Lisbon [5,
p. 2251.
 352 FRANKA.BARRETT
He concludes Part II by making the argument that
criminals should not be executed but be condemned
to serve for life or a certain period in the worst areas.
Since Lind repeatedly has stated that if newcomers to
the hot countries can survive the first year or two that
they have a reasonable chance of good health then his
suggestion is not as harsh as it might at first seem to
be.
Finally, he says that the woollen cloth tunic
and the black head dress of the British soldier are
unsuited to the hot climate and should be modified
[5, pp. 228-2291.
Part III, with 40 pages is the shortest part of the
main body of the essay and is medical rather than
geographical. As such is not pertinent to this paper
other than to note that it contains two chapters; one
titled, Directions for the cure of those diseases which
attack strangers in warm climates, and the other,
Directions for the benefit of those whose consti-
tutions have been impaired abroad. There is also an
appendix containing lengthy notes on; Concerning
agues, and Linds method of producing drinking
water while at sea.
Thus the major part of his essay is a geographical
study of the regional and systematic factors influenc-
ing the health of Europeans in hot lands. As such
Lind demonstrates that by carefully considering the
characteristics of site, location, and the inter-relation-
ships of place, that important observations about the
geography of diseases could be made and that as a
physician he could then translate these into rec-
ommendations that had some chance of alleviating
sickness. These observations and recommendations,
long before the cause of malaria was discovered
emphasize an important point. Because in Linds time
and for nearly a 125 years after, the cause of tropical
fevers and fluxes was not identified, we seem to
assume that they could not take preventative
measures. We are wrong. By focusing on site, lo-
cation, and the characteristics of place observant men
could and did make meaningful recommendations
that reduced morbidity and mortality. From the
observations and conclusions that Lind made, while
he did not know the causative factors of the fevers,
he certainly recognized the major associative
occurrences of insect transmitted diseases. His
recommendations noted above, when followed, plus
the use of chinchona bark which he strongly
favoured, would cut the morbidity rate and reduce
the mortality rate. His medical geographical
approach, which led him to numerous practical
observations, demonstrates that it was a valuable
approach. His careful inductive reasoning, based on
empirical evidence, illustrates the potential of
geographical reasoning. He shows how a careful
consideration and evaluation of site, location, the
characteristics of places, and comparative regional
examination lead to a better understanding of how
the chances of sickness could be reduced at a time
when the specific cause was unknown.
As an astute physician James Lind did what other
astute physicians had done before him and more were
to do in his path. They recognized that there is a
geography of disease and that by using geographical
concepts a greater knowledge about the nature of
disease could be discovered.
There are two final and important points to which
I must draw your attention.
In the introduction I suggested that James Linds
book, An Essay on the Diseases Incidential to
Europeans in Hot Climates: with the Method of
Preventing their Fatal Consequences, appears to be an
unknown book to most medical geographers. There-
fore, the question arises, what was the impact of this
book on his contemporaries and colleagues?
The book was very popular in its time and went
through six editions plus translations into Dutch,
French, and German [lo, pp. 160-1631. Although
today, when the name of Lind is mentioned, it is
usually only in the context of his work on scurvy. In
a sense he is like Pasteur, whose name is popularly
remembered now for the process of purifying milk,
but, like Pasteur, Linds importance, as we have seen,
is greater than a single discovery. He made several
valuable advances in knowledge which lead to im-
provement in peoples health. Lind thought that his
work on Europeans in Hot Climates was very
important and it became a much greater interest to
him than scurvy [ll].
Shortly, I shall be placing Linds work in context
with other studies of medical geography and geo-
graphical medicine of the 18th century [12]. However,
for the present there is still one more tantalizing
observation that I wish to draw to your attention.
Generally, it is thought that L. L. Finkes three
volume work, Versuch einer allgemeinen medicinisch-
praktischen GeographielAttempt at a universal medi-
cal-practical geography. 1792-95, is the first example
of an attempt at a world medical geography [13]. But
in view of my contention, that Linds book is clearly
a medical geography, in fact if not in name, and that
it predates Finkes work, then based on present
evidence, it was Lind and not Finke who was the first
person to write a medical geography at a global scale.
Since Linds essay was published nearly 25 years
before Finkes work, the seminal question is, was
Finke aware of Linds book, and did he use it in his
Medical Geography? Finke says in the introduc-
tion to volume one that, Hippocrates book on air,
water and regions is the only one known to me that
is somewhat similar to a medical geography [13, 1,
p. xxxv]. This appears to be a pretty clear-cut state-
ment but, in fact, it is very misleading. The evidence
is as follows. In the indices of Finkes work there are
three references to James Lind. In view of Linds
fame, due to his earlier works on scurvy, and the
health of seamen, it is of interest that Finke does not
cite either of these two books. Instead, he cites An
Essay on Diseases Incidential to Europeans in Hot
Climates, which from a medical geographical perspec-
tive, is more appropriate and logical. This indicates
that Finke was at least aware of Linds medical
geographical approach. Still, only three references
does not seem to indicate that the book had much
impact on Finke.
On a hunch I disregarded the index in Finkes book
and carefully examined all 2390 pages of Finkes
three volume work. Instead of the 3 references to
Linds Europeans in Hot Climates in the three
volumes, I found 78 references! Of these 73 were in
volume one, the volume in Finkes work that covers
the tropics. Indeed, of these 73 references, 51 were
 Scurvy Linds medical geography
specific page references from Linds essay. Therefore,
the proof from Finkes own book is clear. He not
only was aware of Linds study but he borrowed
heavily from it. In the context of his citations he
obviously thought it an important source with valid
ideas.
Therefore, one must conclude, contrary to the
assumption in contemporary medical geographical
literature that the Germans and French were the only
major contributors to the development of medical
geography, that the British physician, James Lind
made an important contribution to the development
of medical geography and geographical medicine.
REFERENCES
Barkhuus A. Medical geographies. Ciba Symposia 6/10,
1997-2016, 1945.
Howe G. M. Nabonal Atlas of Disease Mortality in the
United Kingdom. Nelson, London, 1970.
See Refs [I] and [2]; Barrett F. A. Medical geography
as a foster child. In Conceptual and Methodological
Issues in Medical Geography (Edited by Meade M. S.),
pp. I-15. Studies in Geography No. 15, Department of
Geography, University of North Carolina, Chapel Hill,
N. C., 1980; Eighteenth century antecedents of medical
geography. In Geografia Medico: Prim0 Seminar0 Inrer-
nazionole (Edited by Arena G. and Palagiano C.),
pp. 129-145. Edizioni Rux, Perugia, 1983; The origins
of medical geography in France: a preliminary note on
an early contributor. In Actes du Symposium du GPogra-
phie de la Sunth (Edited by Picheral H.), pp. I-13, 25th
Congress, International Geographical Union, Montpel-
her, 1984.
Lind J. An Essay on Diseases Incidental to Europeans in
hot Climates: with the Method of Preventing their Faral
Consequences. Becket and De Hondt, London, 1768.
353
5. Howe [2] briefly mentioned this book in the introduc-
tion of his atlas. But, when I read his historical review
several years ago, the reference to Linds book had not
registered in my memory. To the best of my knowledge
no other contemporary medical geographer has cited
this work.
6. Garrison F. An Inlroduction IO the History of Medicine,
4th edn. Saunders, Philadelphia, 1929.
7. Singer C. and Underwood E. A. A Short History of
Medicine. Oxford, London, 1962.
8. Curtin P. D. The Image of Africa: British Ideas and
A&on, 178&1850. University of Wisconsin Press,
Madison, 1964. Although Linds work on Hot
Countries is known to tropical medicine historians and
students of West Africa and of the Slave trade as Curtin
ably demonstrates in this book, Linds work appears to
be unknown to present day medical geographers aside
from Howes [2] comments.
9. Elsewhere I have discussed the difference between
medical geography and geographical medicine.
Barrett F. A. Medical geography concept and defi-
nition. In Medical Geography:.Progress and Prospect
(Edited bv Pacione M.), DD. l-34. Croom Helm.
I. _.
London, i986.
10. Roddis L. H. James Lind: Founder of Nautical Medicine.
Heinemann, London, 1951.
11. I am indebted to Mr. H. J. M. Symons, a Senior
Librarian at the Wellcome Institute for the History of
Medicine, London, England, for this information and
indeed for 12 years of his advice and scholarly knowl-
edge of the history of medicine.
12. I am currently writing a book titled, The Origins
and Development of Medical Geography and Geogra-
phical Medicine: From the Mid-5th Century B.C. to
the Mid-20th Cenrury A.D. Chapters 6, 7 and 8
deal with the many eighteenth century sources
that place Linds work in the broader context of that
period.
13. Published in 1792-95 by Weidmann, Leipzig.