In message <F10DE59FA201D211989800805FD4E36B05DCB3A4@exchange_01>,
Andrew Jull <[log in to unmask]> writes
> If trials or SR/MAs become seminal, then the date of publication is
>surely of minimal concern, unless the therapy is superceded by new and more
>cost-effective treatments. Of course this does raise the issue of how long a
>paper should be regarded as seminal?
>
>
Well - imagine someone saying that James Lind's 1747 clinical trial of
remedies for scurvy was methodologically riddled with faults? Judge for
yourselves:
"On the 20th May, 1747, I took twelve patients in the scurvy on board
the Salisbury at sea. Their cases were as similar as I could have them.
They all in general had putrid gums, the spots and lassitude, with
weakness of their knees. They lay together in one place, being a proper
apartment for the sick in the fore-hold; and had one diet in common to
all, viz., water gruel sweetened with sugar in the morning; fresh mutton
broth often times for dinner; at other times puddings, boiled biscuit
with sugar etc.; and for supper barley, raisins, rice and currants, sago
and wine, or the like. Two of these were ordered each a quart of cyder a
day. Two others took twenty five gutts of elixir vitriol three times a
day upon an empty stomach, using a gargle strongly acidulated with it
for their mouths. Two others took two spoonfuls of vinegar three times a
day upon an empty stomach, having their gruels and their other food well
acidulated with it, as also the gargle for the mouth. Two of the worst
patients, with the tendons in the ham rigid (a symptom none the rest
had) were put under a course of sea water. Of this they drank half a
pint every day and sometimes more or less as it operated by way of
gentle physic. Two others had each two oranges and one lemon given them
every day. These they eat with greediness at different times upon an
empty stomach. They continued but six days under this course, having
consumed the quantity that could be spared. The two remaining patients
took the bigness of a nutmeg three times a day of an electuary
recommended by an hospital surgeon made of garlic, mustard seed, rad.
raphan., balsam of Peru and gum myrrh, using for common drink barley
water well acidulated with tamarinds, by a decoction of which, with the
addition of cremor tartar, they were gently purged three or four times
during the course.
The consequence was that the most sudden and visible good effects were
perceived from the use of the oranges and lemons; one of those who had
taken them being at the end of six days fit for duty. The spots were not
indeed at that time quite off his body, nor his gums sound; but without
any other medicine than a gargarism or elixir of vitriol he became quite
healthy before we came into Plymouth, which was on the 16th June. The
other was the best recovered of any in his condition, and being now
deemed pretty well was appointed nurse to the rest of the sick"
Is this convincing evidence for the effectiveness of oranges and lemons
in the treatment of scurvy or should we demand a properly run double
blinded RCT?! Actually I think Lind did brilliantly to design a
scientific clinical trial from scratch - and he had even done a
literature search first - the remedies mentioned were those he found in
his reading.
Toby
--
Toby Lipman
General practitioner, Newcastle upon Tyne
Northern and Yorkshire research training fellow
Tel 0191-2811060 (home), 0191-2437000 (surgery)
Northern and Yorkshire Evidence-Based Practice Workshops
http://www.eb-practice.fsnet.co.uk/
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