Tröhler U (2007). An early 18th century proposal for improving medicine by tabulating and analysing practice.
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© Ulrich Tröhler, Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland, Email: ulrich.troehler@ispm.unibe.ch


Cite as: Tröhler U (2007). An early 18th century proposal for improving medicine by tabulating and analysing practice. JLL Bulletin: Commentaries on the history of treatment evaluation (http://www.jameslindlibrary.org/articles/an-early-18th-century-proposal-for-improving-medicine-by-tabulating-and-analysing-practice/)


In his book The state of physick ancient and modern briefly considered with a plan of improvement of it (Clifton 1732), Francis Clifton (†1736), a successful London physician, saw himself in the tradition of learned physician-historians such as Daniel Le Clerc (1652-1728) and John Friend (1675-1728). As a critic of contemporary medicine he felt himself in line with Francis Bacon (1561-1626), the much revered 17th century statesman, scientist and theoretician of early modern science. When writing this book, Clifton was relatively young. Although his date of birth is not known, he gained his medical Doctorate at the University of Leiden in 1724, so he was probably in his early thirties, yet he had already become a Fellow of the Royal Society and of the Royal College of Physicians (in 1727 and 1729, respectively). He also held a rare honorary MD degree from the University of Cambridge, and had had an appointment as physician to the Prince of Wales for some years. He was quite well known as an editor and writer because of his edition of, among others, the works of Hippocrates in Latin.

The year before The state of physick… was published, Clifton’s preoccupation with the Hippocratic ideal of medical practice (see below), and with medical history in general, had led him to criticise certain features of contemporary medicine, and he had conceived a plan for changing the basis of medical research and practice. This publication, entitled Tabular observations recommended as the plainest and surest Way of practising and improving physick in alLetter to a friend (Clifton 1731), had aroused criticism.  As he now wrote in the preface to his new book, his critics suggested that “[ …]out of an over-fondness for the Ancients I had slighted the Moderns too much“ (unnumbered p. III).

In Clifton’s opinion, this was only a polemical attack, which did not address the truths supported by his analysis: “I said what I really thought; and I have no reason since to alter my opinion, as to the usefulness of observations in Physick in opposition to Schemes and Theories” (ibid.). Specifically, he claimed to know “from experience” that medicine was often uncautiously used, in concurrence rather than in agreement with nature, so that the physician himself became a danger: “Good God!” he exclaimed, “how is it possible that men of understanding shou’d ever have acted such a part as this?” (p 155).

Moderns, besides their frequent use of Physick without indications,” he continued, “are grown so excessively fond of it, that the Patient is too often overloaded with it; and so the Art, that was intended for his preservation, is thereby made (I am sorry to say it) the instrument of his destruction; Nature being unable to recover herself from one oppression [i.e. a disease], before another [i.e. medicine] is thrown upon her”

This “excess” was not only a scientific and moral “folly” but also a social “impolitickness” (p 156).

Clifton made clear that the practice of the Ancients following the time-honoured Hippocratic ideal of supporting Nature in overcoming disease was certainly much preferable to intervening according to fashionable learned ideas: “What does all our knowledge signify”, he asked rhetorically, “if we are above observing those things that are absolutely necessary to make a man a wise and good Physician?” (p 156). According to Clifton, the “[q]ualifications necessary for a good Physician” were “attention”, “sagacity”, “disinterestedness” and “diligence”. But only a few had had them in the past or had them now, for “ [t]is easier to make a learned harangue.” (p 158). And that was why, a year previously, Clifton had proposed his “Tabular Observations” as a practical solution to these deficiencies.

In his new work (Clifton 1732), Clifton now republished the text of his earlier book as a section entitled A plan for the improvement of physick , because this was the logical quintessence of his view of the history of medicine. His plan consisted of re-evaluating the Hippocratic method of case histories, the neglect of which Bacon had deplored when criticizing the medicine of his time, a hundred years earlier. Although the method was correct, however, Clifton noted that, because “the Observations of the Ancients [made in Greece] are of no use in England”, “[L]et us [therefore] industriously enquire how the case really stands here” (p 170).

As the core of his Plan, Clifton recommended a table for making regular, standardized recordings of clinical observations about the diseases in England at that time. The six columns of the table contained the personal data of the patient –  sex, age, species [?], temperament, occupation, victus aegri [the patient’s constitution], the disease phenomena, the date, the treatment, and the outcome – all listed day-by-day. These parameters reflected the ancient holistic concept of medicine. Clifton added two examples of completed tables .

Clifton was a very practical man. He realized that the table would become gigantic (and expensive) if one noted down all observations in detail. He therefore recommended abbreviations in Latin or Greek: “one Greek word will express that which requires many words in Latin, and even more in English”. In concluding his book he wrote: “Nor will I ever write upon any subject, as a Physician, for which I have not tabular authority […] but for some people authority is all in all.” (p 180).

Tabulations were not entirely new in the advanced medical world of London’s Royal Society. During the 1720s, the Society’s one-time secretary, James Jurin (1724), had summarized 17th and early 18th century mortality rates from smallpox in tabular form, and Scheuchzer (1729) had continued to do so for subsequent years. These tables were all published in the Society’s Transactions and were debated in its meetings (Huth 2005). Clifton’s Plan was also discussed at a meeting of the Royal Society in April 1731. The Society’s secretary at the time, Cromwell Mortimer, a physician himself, flagged “the new kind of Table” as a significant invention – “a break from traditional forms of medical writing” – which he supported:

So that the Labour of the Physician is thus greatly eas’d and the Observations at once properly rang’d, or class’d for Inspection and use. […] [U]pon this footing Disease might possibly, in time, be found to be as regular in their Course as any other Phænomena, and cur’d with as much ease as they are now contracted. (as quoted in Rusnock 2002).

According to Clifton and Mortimer, therefore, these tabulations were useful in two ways: they “facilitate[d] the business of Observation”, and promoted systematic, comparative analysis by easing classification.

Clifton’s proposal was recognised to have a shortcoming: it depended on the assessment of prevailing disease “by individual physicians, who in turn relied upon their private practice.”  To address this problem, Clifton, like Bacon before him, proposed a kind of hospital statistician, employed to “set down the cases of the patients there from day to day, candidly and judiciously”, that is, without any regard to private or public opinions, or interests. The statisticians would publish these facts “at the year’s end […] leaving every one to make the best use of ‘em he can for himself.”

Returning to the stance against theorising that he had expressed in the Preface to The state of physick, Clifton asked rhetorically whether such a method would not

let us more into the Nature of diseases in a few years, than all the books of Theories, or even the books of [unsystematic] Observations, hitherto publish’d?.

This James Lind Library commentary has been republished in the Journal of the Royal Society of Medicine 2010;103:379-380. Print PDF

References

Clifton F (1731). Tabular observations recommended, as the plainest and surest way of practising and improving physick, etc. London: Brindley.

Clifton F (1732). The state of physick, ancient and modern, briefly considered: with a plan for the improvement of it. London printed by W Bowyer, for John Nourse without Temple-Bar.

Huth EJ (2005). Quantitative evidence for judgments on the efficacy of inoculation for the prevention of smallpox: England and New England in the 1700s. The James Lind Library (www.jameslindlibrary.org).

Jurin J (1724). A letter to the learned Dr. Caleb Cotesworth, F. R. S. of the College of Physicians, London, and physician to St. Thomas’s Hospital; containing a comparison between the danger of the natural small pox, and that given by inoculation. Philosophical Transactions of the Royal Society of London (1722 – 1723), 32:213-227.

Rusnock A (2002). Quoting Register Book Copy of the Royal Society, RBC.15.344. In: Vital accounts. Cambridge: Cambridge University Press, p 123.

Scheuchzer JG (1729). An account of the success of inoculating the small-pox in Great Britain, for the years 1727 and 1728: With a comparison between the mortality of the natural small-pox, and the miscarriages in that practice; as also some general remarks on its progress. London: J.Peele.