Chapter 11. Evidence-based medicine

Rene Descartes

While Renaissance scientists, despite their innovations, often borrowed knowledge from ancient times, enlightenment scientists were completely focused on new ideas. Rene Descartes in France, as well as Francis Bacon in England, proposed a direction — rationalism, free from the religious dogmas of the time, as a means of promoting science. The scientific approach at this time led to significant achievements in the field of physiology, histology, the discovery of bacteria, and the first vaccination.

It is in his arguments about the method of correct search for truth in the Sciences, Rene Descartes (1596–1650) laid the foundations of rationalism in his work «Reasoning about method» (1637) (Fig. 11.1).

Fig. 11.1. Rene Descartes (1596–1650) — French philosopher, mathematician, and physiologist

Having proposed a logical and almost mathematical model of the sequence of reflection, Descartes finally said goodbye to the scholastic idea and initiated the dominance of scientific thought. He contributed to the development of science by introducing analytical geometry and discovering the law of optical refraction.

However, you can find a distant echo of Descartes’ thoughts in the fashionable concept of «evidence-based medicine» in the last 20 years, especially in rheumatology, which was perfected by epidemiologist Archie Cochrane.

It is very paradoxical, from our point of view, that evidence-based medicine has its roots in the era of great metaphysical discoveries. On the one hand, the great Georgian discoveries are a reference point in history that closes the Middle Ages. On the other hand, it was still the first step towards globalization, which is undoubtedly relevant to the problem under consideration. In particular, it is known that substances for chondroitin sulfate are produced either in Argentina or in Spain, with production chains and end-users located on different continents.

A specialist who evaluates risk factors in a comorbid patient in a rural outpatient setting can reason in accordance with the results of a recently published meta-analysis of the effectiveness and safety of new forms of NSAIDs, published again on another continent. However, all the advantages of globalization and the influence of producers for global markets would not have been possible without those great geographical discoveries.

The need for long-term isolation of ship crews formed the ideas of ship’s doctors about previously poorly studied nosologies.

Beriberi sample of the 16th century

Scurvy has become the Bane of sailors since the voyages have lasted longer than a few weeks. The first documented evidence of this disease dates back to 1497, when Vasco da Gama rounded the Cape of Good Hope.

Known to us from the time of school geography circumnavigation, F. Magellan lasted a little less than 3 years (20.09.1519–06.09.1522). At the same time, out of 260 (according to some data, 280) crew members on 5 ships, only 18 returned on one ship, the fate of the other team members was sad, including F. Magellan himself, however, the expedition was very successful commercially, bringing the organizers a large profit.

There is also a ship’s log recorded by expedition member Antonio Pigafetta in four versions, one in Italian and three in French, who was lucky enough to be among the 18 crew members who successfully completed the first circumnavigation of the world. One copy in French is available at the Yale University library.

Based on these records, it is known that problems with discipline began already off the coast of Brazil, 3–4 months after the start of the expedition. What was the contribution of scurvy to the mood of the sailors is difficult to judge, but the difficult situation was off the coast of modern Uruguay, where the Gulf of La Plata was taken for the tip of South America. After moving North, fresh water was discovered overboard, it became obvious that the water area of the expedition is not the Pacific ocean, but only a river that goes deep into the continent, which may have served as a message for part of the crew, who began to hatch plans to desert.

Already within the limits of the modern Strait of Magellan, after Magellan once again cut the onboard ration, the crew of the ship «San Antonio» decided that the risk of desertion is more justified than continuing previously unknown chronic diseases. Note that the crew of San Antonio managed to return to Spain.

The author of the ship’s log also points out that the health of the crew improved significantly after tropical fruits became available on the Pacific Islands after March, 1521. This is confirmed by the argument that the leader of the expedition with part of the crew tried to participate in «military» conflicts of local significance, as a result of which he died not from scurvy, but from deliberate trauma.

It is known that the circumnavigation of the world went down in history as the Magellan expedition, but the expedition was completed by Juan Sebastian Elcano, who was able to return to Spain on the same ship with 18 crew members. Antonio Pigafetta also describes in detail the second wave of scurvy that broke out in the crew while the expedition was in the Indian ocean. The tragedy of the situation was that the ship’s hold was filled to capacity with cloves and nutmeg, and 100 grams of nutmeg could cover up to 20% of the daily requirement of vitamin C. Juan Sebastian Elcano took full responsibility for the fate of the expedition and delivered the cargo to the destination port. However, 4 years later, he received a new task from the king, and as part of the next expedition, he still died of scurvy, somewhere in the vast Pacific Ocean.