Case Studies in the Late 17th CenturySeptember 15, 2008
Alan Lovell’s post on the uses of case studies really got me thinking and fishing around on the web – so often in health information we deal only in the higher levels of evidence that it’s easy not to think about the lower-level stuff, especially the one-off cases.
Found a great article by S. Sandassie on the use of patient case studies in surgical treatises in the late 17th century [*]. There’s a lot of good stuff in there, including the proposal that “evidence-based medicine was practised a century earlier than – and across the Channel from – its supposed first emergence in modern medical practice.” (Abstract).
I’m particularly interested in the discussion on why the case studies were included in the treatises (p.15-17). Sandassie found that most of the surgeons referred to other people’s cases as well as their own (p.15-16) and that as well as successful treatments, they “cited a number of cases that were unsuccessfully treated and that resulted in the patient’s death.” (p.15). Sandassie speculates that
In some cases, at least, the authors specifically selected these unsuccessful cases to demonstrate the fallible nature of several methods of treatment. Read, on the other hand, stated that he specifically included one of his own cases that ended in death hoping that it would be useful to the reader, and that it would encourage the young surgeon to think critically about examples, as they are not always beneficial. (p.15)
Another motivation Sandassie detected in some of the treatises was to
attempt to suppress the work of those judged to be unqualified to practice surgery. Turner … denounced … empirical practitioners, quacks or pamphleteers, the barber surgeon, the bonesetter and the doctoress … He lambastes them in turn, providing several cases – the majority ending in either a failure of treatment or the patient’s death – in which these practitioners committed forms of malpractice, were ignorant of the illnesses that they attempted to treat or misrepresented either their ability to cure or their experience. (p.16).
The main theme, though, seems to be one of education:
Wiseman … included a number of unsuccessful cases in his treatise. Noting … the gross errors in care that he had witnessed over the years, he hinted that his aim was to educate the younger generation of surgeons and provide them with applicable methods of cure for their own practices. (p.16)
Sandassie contrasts the use of failed treatments with modern practice in EBM, with its emphasis on best practice, which, she says, “calls into question the purpose of including failed cases at all. The answer may … simply be that the surgeons needed to dispel popular – though unsuccessful – notions of treatment prior to describing those that worked.” (p.17)
With regard to the inclusion of case studies at all, she concludes that:
The reasons varied, as one surgeon cited cases in an attempt to suppress empirics, while others stated that they wrote for the purpose of educating the younger generation, and some explicitly practised, and advocated, evidence-based medicine. (p.17)
This is an interesting piece of work that sparks lots of questions, many of them raised by the author herself in her final paragraph, which calls for further research into this area. We are left wondering with her “Was evidence-based medicine a central component of the professionalism of English medicine, a process in which the 17th century looms large in the standard histories?” (p.18).
Plus ca change?
S Sandassie (2008). Evidence-based medicine? Patient case studies in English surgical treatises, 1660-1700 Medical Humanities, 34 (1), 11-18 DOI: 10.1136/jmh.2008.000266