Commentary: ‘Medical art’ versus ‘medical science’: J Civiale's statistical research on conditions caused by calculi at the Paris Academy of Sciences in 1835

U Tröhler

Institut für Geschichte der Medizin, Albert-Ludwigs Universität Freiburg, Stefan-Meier-Str. 26, Freiburg, Germany.

This report1 results from an in-depth study of a subject considered sufficiently important by the Paris Académie des Sciences to warrant commissioning some members to introduce a formal debate. This was also a normal procedure in the much younger Académie Royale de Médecine, which was founded in 1820. The Civiale report, published on 5 October 1835, must be seen in the context of a contest in contemporary French medical literature about the applicability of ‘statistics' to medicine.

The issue had been launched in a theoretical way in France by the mathematicians Condorcet and LaPlace in the late 18th and the early 19th centuries. Their successors were now reviving their ideas about probabilistic theory: Siméon-Denis Poisson (1781–1840), for instance, a member of the Civiale Commission, was developing his law of large numbers (to be published in 1837).2

Most clinicians, however, lacked a sufficient educational background in mathematics. For them, ‘statistics' meant simply counting ‘facts', both in nosography and therapeutics. Such quantification as means of improving evidence in medicine had been well developed in 18th century Britain, particularly with respect to therapeutic comparisons. British arithmetic observation and experimentation included designs to avoid selection and/or observer bias.3 By the 1820s, counting became a feature of the work at the great Paris hospitals where Pierre Charles Alexandre Louis (1787–1872) termed it méthode numérique. He championed it with his classical studies on phthisis (1825) and typhoid fever (1828), correlating clinical with post-mortem observations made on hundreds of patients.4–6

Jean Civiale (1792–1867) was Louis's contemporary in Paris. His work on the clinical epidemiology and therapy of bladder stones stood in yet another, both international and specifically urological, tradition. Indeed, epidemiological data on bladder stone patients had been collected in various European cities and for various motives. A case in point were the exemplary registers of the Norfolk and Norwich Hospital. In Norwich civic records existed for the whole of the 17th century. Both had been used by British investigators such as Matthew Dobson (1779) and, more recently, Alexander Marcet (1817) or John Yelloli (1821, 1828/29), the latter contributing a sober debate about calculations of average mortalities with his physician-chemist colleague William Prout. As to treatment, arguments for one of the many new technical variations of traditional lithotomy (i.e. extraction of the stone from the bladder) propagated in the 18th century were underpinned throughout Europe in terms of comparative success and failure rates. Such figures were often disclaimed by the proselytes of another method using arguments regarding patient selection, age, lack of precise records or even outright cheating.3

Thus, Civiale's approaches were not new, but he had collected data on a considerably larger scale. The sponsorship of the Ministry of Public Instruction after the political changes following the revolution of 1830 had enabled him to do so.6 This context illustrates the importance attributed to bladder stones in early public health efforts as well as in clinical medicine.

Jean Civiale was a Paris-trained doctor who had been interested in bladder stones since his student days. He had first tried in vain—as so many had before him—to dissolve them chemically. In January 1824 he had been the first to try mechanical intravesical crushing with an instrument introduced via the urethra, in a public demonstration. In 1826 the Académie des Sciences awarded him a prize for this lithotripsy. The year after he received the Prix Montyon—a highly valued 19th century precursor of the Nobel Prize. In 1828 he was appointed director of a special ward for bladder stone patients at the Necker Hospital in Paris: Civiale was a successful man, indeed.7,8

Quite naturally he keenly propagated his innovative method of treatment which he considered much safer, as evidenced by a recovery rate of 98% according to his own results, compared to the 78% he had calculated after aggregating statistics on thousands of lithotomies. But he was not the only inventor of lithotripsy; his procedure would not prevent relapse, and it promoted inflammation. In fact, the history of the treatment of bladder stones in France and Britain over this period corresponds to battles between lithotomists and lithotriptists on the one hand, and among lithotriptists themselves (about the priority of invention) on the other hand, and these battles were often fought with the statistical weapons.

Another aspect of this report,1 and perhaps the most interesting one from a present day perspective, is that it was used ‘to engage the broader issue of the proper function of the medical profession within society as a whole’.6

The reporter, Francois-Joseph Double (1777–1842), was a leading physician of the Paris medical establishment, as was the other clinician and member of the Committee, Napoleon's famous surgeon, Dominique-Jean Larrey (1766–1842). Pierre-Louis Dulong (1785–1838) was a physician-chemist along the lines of Marcet, Prout and Yelloli. Poisson, the mathematician, was at that time quite sceptical about the applicability of his science to medical issues, as was Double, albeit for quite other reasons: The principal author of the report, Double, held that statistical thinking in terms of masses and groups undermined the notion of the patient's individuality. Furthermore, the clinician's specific art médical would be lost by non-medical scientists setting up fixed rules for doctors' decisions about phenomena which were essentially variable. Furthermore, they would do so on the basis of probable results threatening to replace the certain knowledge derived from logical dogmatic systems and personal experience. In short, the clinician was not an empirical scientist but a humanitarian healer.6

Poisson criticised the simple cookbook arithmetic used by clinicians, but at the same time formulated reservations about the feasibility of mathematically sound therapeutic comparisons requiring 212 comparable patients in each group (according to his standards).

Civiale, who was considerably younger than the members of the Academy Commission, argued—as his 18th century British predecessors would have done and as would Louis—that only numerical results from pathological observations and all inclusive records of treatment successes and failures could avoid the fallacies of trusting memory alone.

Double made no concessions to the numerists. He claimed that medical knowledge did not suffer from a lack of certitude because it could not meet the rigorous demands of ‘the calculus of probability’: Morgagni's saying that ‘facts need not to be counted but need to be weighed’ (1761) was true and decisive. Giovanni Battista Morgagni was the 18th century ‘father’ of the anatomo-clinical method dear to Paris medicine in the early 19th century. Note that the mathematician Poisson and the clinician Double both used ‘calculus of probabilities', but without understanding each other. While Poisson meant it in today's sense, for Double it was a rhetorical expression of opposition to proper medical reasoning by inference from analogies.

Clearly this debate in the Academy of Sciences could neither satisfy Civiale, the urologist, nor the physician Louis and his followers. In 1837 a similar debate arose in the Academy of Medicine about the latter's questioning, with numerical evidence, of the value of bloodletting, highly fashionable in the Paris of that time, to treat typhoid fever. And, of late, the debate is again with us, in the contested claims about evidence-based medicine.

References

1 Poisson SD, Double FJ et al. Rapports: Recherches de Statistique sur l’affection calculeuse, par M. Le docteur Civiale. Comptes Rendus Hebdomadaires des Séances de l’Académie des Sciences 1835;1:171–72.

2 Murphy TD. Medical knowledge and statistical methods in early nineteenth-century France. Medical History 1981;25:301–19.[ISI][Medline]

3 Tröhler U. ‘To Improve the Evidence of Medicine’: The 18th Century British Origins of a Critical Approach. Edinburgh: Royal College of Physicians, 2000.

4 Ackerknecht EH. Medicine at the Paris Hospital, 1794–1848. Baltimore MD: Johns Hopkins Press, 1967.

5 La Berge A, Hannaway C. Paris Medicine: Perspectives past and present. In: Hannaway C, La Berge A (eds). Constructing Paris Medicine. Amsterdam: Editions Rodopi, 1998, pp.1–69.

6 Matthews JR. Quantification and the Quest for Medical Certainty. Princeton: Princeton University Press, 1995, pp.20–22.

7 Kiefer JH. Jean Civiale 1792–1867. Investigative Urology 1968;1:116–17.

8 Egli N. der ‘Prix Montyon de physiologie expérimentale’ im 19 Jahrhundert. Zürich: Juris (Zürcher Medizinhistorische Abhandlungen n. R. Nr. 72) 1970.





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