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Quantification and the Quest for Medical Certainty.

Social constructionist interpretations now capture even the formerly pristine field of mathematical techniques. This important, if labored, recent Duke dissertation demonstrates that concepts of medical objectivity depended partly on professional and institutional support. For a century and a half, notions of objectivity among clinical physicians, physiologists, and bacteriologists branded as irrelevant the rival concepts of statisticians. Clinical physicians accepted statistics only under pressure for drug testing after World War II and after considerable institutional support from the legacy of Francis Galton at the University of London. In fact, the randomized clinical trial appeared as recently as 1946, and the public furore over the mayhem caused by thalidomide resulted in 1962 in U.S. legislation, imitated world-wide, requiring double-blind drug tests.

Matthews builds on the work of Theodore Porter, who maintains that quantification is a sign of a need by experts for public endorsement, and also of the "taming of chance" explored by Ian Hacking. Many earlier issues still show up in the debates about the overriding commitment to healing versus careful testing before administering possibly life-saving drugs. Using Allan Megill's classification of kinds of objectivity, Matthews contrasts the physicians' "disciplinary" objectivity -- what would make medicine scientific -- with the statisticians' formal "rules."

In the nineteenth and early twentieth centuries, French clinicians, German physiologists, and, later, British bacteriologists bad clear notions of their own claims to reliable science. In fact, the early opponents of Pierre Louis of the Paris Clinical School, Francois Double and Risueno d'Amador, in the French Academy of Medicine in 1837 argued that the "art" of medicine would be perverted by aggregative thinking. A minor flaw in Matthews's argument is his assignment of Cabanis wholly to the "artistic" side of the dispute before 1808, while in fact the analytical, Baconian method for medicine unwittingly led to a statistical approach to the clinic. Double claimed that inherently "fictitious" therapeutic averages were no more valuable in treatment than trying to fit each patient with an average shoe. There is strange resemblance here to some current critiques of psychological norms by Kurt Danziger.

Both French and German physicians found impossibly high standards for significance in the path-breaking statistical work of the engineer Jules Gavarret (1840). Later, experimental physiologists such as Claude Bernard disparaged statistics as being insufficiently deterministic. In Germany in the 1850s physiologists such as Karl Vierordt rejected physicist Gustav Radicke's work on medical observational error and deviation. They claimed that only trained physiologists could design experiments without systematic error, and that statisticians exaggerated the need to eliminate mathematical error.

The vividness of Matthews's account improves once he explores the personal papers of Francis Galton, Karl Pearson, and the U.S. medical statistician Raymond Pearl. Here the biometrical imperative established in the University of London provided a home for Pearson's student, Major Greenwood. When bacteriologist Almroth Wright claimed a successful vaccine for typhoid, based on an "opsonic index" of blood antibodies, Greenwood showed in 1908 that the frequency distributions were skewed. The inheritor of this tradition was Austin Bradford Hill, the first architect of the successful clinical trial of streptomycin against tuberculosis. By the 1950s, under societal pressure to test antibiotics, physicians were inclined to accept that statisticians should both design and interpret experimental procedures. Statistical notions of objectivity had at last fused with concepts of scientific medicine.

Matthews's eight-page conclusion brings the reader up-to-date concerning all the recent controversies about clinical trials, including the problem of whether testing should be done on female, less wealthy, and nonwhite populations. Better integration of the debates in the conclusion into the remainder of the text would have sharpened the analysis. His account certainly shows that the social context of science affects ideas of objectivity. At the same time, it would be difficult not to see some justification for a medical triumphalism (not explicitly endorsed by Matthews) in a story of assuring more reliable testing, however flawed, of therapeutic outcomes. Matthews cites modern clinicians' rule of thumb in asking of any protocol whether the physicians themselves or their relatives would be ready to assume the risks of participating in the trial. Similarly, one might ask of the post-modern critics of expertise and objectivity whose views are briefly described by Matthews whether, if they were ill, they would accept medication which had not been clinically tested.
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Author:Staum, Martin S.
Publication:Canadian Journal of History
Article Type:Book Review
Date:Aug 1, 1996
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