"To Improve the Evidence of Medicine": The 18th Century British Origins of a Critical Approach · Knowledge and Practice in English Medicine 1550–1680

“To Improve the Evidence of Medicine”: The 18th Century British Origins of a Critical Approach by Ulrich Tröhler. Royal College of Physicians of Edinburgh, £10, pp 147. Rating: ★★★★

Knowledge and Practice in English Medicine 1550-1680 by Andrew Wear. Cambridge University Press, £16.95, pp 496. ISBN: 0 521 55827 1. Rating: ★★★

To future medical historians, the last decade of the millennium will be perhaps most noteworthy for the remarkable renaissance in articles and books on evidence based medicine. In the first monograph here, Ulrich Tröhler, a distinguished Swiss physician and medical historian, reminds us that evidence based medicine is not a new concept and can be traced back to 18th century British origins.

The title of the book is taken from George Fordyce's Attempt to Improve the Evidence of Medicine, published in 1783. This was an example of the new philosophical school of rational empiricism which set about challenging the 17th century dogmatic rationalism of Francis Bacon and John Locke. Publications in the 18th century calling for a more critical evidence based approach to medicine included The Improvement of Medicine in London (1775) by John Lettsom (founder of the Medical Society of London), John Gregory's Observations on the Duties and Offices of a Physician (1770), and John Aikin's Thoughts on Hospitals (1771).

The 18th century in Britain saw the proliferation of learned societies and journals for the dissemination of ideas encouraging dissent and honest analysis of the successes and failures of medicine. Quantitative analysis of data was pioneered in military hospitals and gradually began to infiltrate the journals. Richard Mead and William Cullen made pioneering studies on fevers. Cheselden at St Thomas's introduced the keeping of accurate records that enabled him to analyse the morbidity and mortality of his lithotomy operation for bladder stones. James Lind used the controlled clinical trial in 1747 to show that fruit juice given to sailors reduced scurvy. This study put the therapeutic clinical trial on the medical map for future generations.

Professor Tröhler's scholarly monograph is a fascinating study of 18th century medical pioneers who used quantified observations to challenge the dogmas of their time and laid the foundations of today's evidence based medical practice.

Andrew Wear's book covers 16th and 17th century British medical practice, an era which cannot lay much claim to be evidence based in its approach. This monograph attempts to synthesise early British medical practice, setting it in its cultural and social context. This was the era of plague, typhus, malaria, high infant and maternal mortality, and low life expectancy (36 years). Doctors were divided into learned physicians, barber-surgeons, and quacks. Pox or syphilis was ubiquitous and remedies for illnesses were few and often not effective. Infectious diseases rather than chronic degenerative diseases were the order of the day, and the majority of the population lived in poverty and squalor. This was a time of entrenched conservative medical practice with few challenging untested dogmas. Consequently, few major medical advances were made in this period of British medicine.

See Personal view on p 349.