The History of Evidence in Medicine

Francois Joseph Victor Broussais (1772-1838) was a professor of General Pathology at Paris and one of the leading physicians in France. His central theoretical model of disease physiology was that vital processes depended on external stimuli, especially heat; these stimuli produced chemical changes, which modified normal tissue function. He conceived that if the stimuli are in balance, one is healthy, but if they are too weak or too strong, disease results. All disease is local, he held, but is transmitted to other organs by sympathy or via the gastrointestinal mucosa; he believed gastroenteritis was the basis of all pathology (Table 1.1).

P.C.A. Louis (1787-1872), a French contemporary of Broussais, agreed with Broussais that objective observation is central to medicine, but in their methods of observation and the conclusions they drew, their views diverged greatly, and this is why Louis has the more-lasting legacy in the annals of medicine. Louis devoted himself to the observation of inflammatory diseases such as typhoid fever and pneumonia. Until his time, bloodletting (using leeches) was the unchallenged treatment for inflammatory disease. Louis and a few contemporaries were the first to question explicitly whether full-force application of leeches was appropriate under all circumstances, and Louis was the first to test the hypothesis. To address this question, Louis examined the medical records of 79 pneumonia patients in his practice and analyzed their disease duration and mortality experience with respect to the time of their first bleeding relative to the course of the disease. He also took into account the number of bleedings and the subjects' ages. Of note, he started the investigation with a belief that bloodletting was effective. The finding of the study, that the beneficial effect of bloodletting was "much less than has been commonly believed," probably contributed to the demise of bloodletting as a widespread practice.3

TABLE 1.1. Historical landmarks in the development of evidence-based medicine.

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