Quantification in British Medicine and Surgery 1750-1830, with special Reference to its Introduction into Therapeutics A Thesis presented by Ulrich Tröhler, M.D. For the Degree of Doctor of Philosophy in the University of London University College London 1978 18.10.2006 ABSTRACT ULRICH TRÖHLER, M.D.: QUANTIFICATION IN BRITISH MEDICINE AND SURGERY 1750-1830, WITH SPECIAL REFERENCE TO ITS INTRODUCTION INTO THERAPEUTICS The aim of this thesis has been to enquire into the development of mathematical methods of assessment in the study of disease and treatment. The traditional view has been t ha t quantitative analysis was "delayed" until around 1830 when it became recognized as an achievement at the Paris hospitals. The principal reasons advanced to account for this delay are t hat large hospital Services hardly existed in the l8th Century, and that the imperfect state of pathology prevented sufficient identification of disease entities. Furthermore, Paris was a centre for mathematical science, and the quest for certainty in medicine acquired a considerable momentum there from the late 1820s. Upon examination, these factors have been found inadequate to account for this delay äs a European phenomenon: For instance my re-search on British medicine from 1750-1830, concentrating on the major medical problems within the growing towns and the armed forces (fevers, scurvy, syphilis, midwifery and the major surgical operations), has un-earthed a much earlier, deliberate use of quantification in clinical medicine. This thesis describes a movement comprising doctors who were promoting the analysis of (mass) observations by simple arithmetic äs a new and the only sure way to gain certainty in medicine. They have thus been termed "arithmetic observationists". The movement took distinct shape in London, the provinces, and in the Navy around 1780. Thereafter, the method spread steadily despite Opposition, becoming a Standard technique äs revealed in the publications of authors associated with dispensaries, specialized hospitals and the armed forces in the early 19th Century. This thesis also discusses, in philosophical, social and institutional terms, the origins, significance and limitations of this movement, and its men both in civilian and military life. 18.10.2006 My conclusions are l) that historiographically the French contributions to quantitative nosography and evaluation of therapy, and the many subsequent endeavours right up to the early 20th Century, should be reconsidered in the light of these earlier British achievements, and 2) that arithmetic observationism marked a shift away from reliance upon Authority,to personal responsibility. For, to work credibly, the investi-gator required, as he still does, the observation of stringent moral Standards both in the conduct of research and in the Interpretation of results. 18.10.2006 ACKNOWLEDGEMENTS I should like to express my sincere gratitude to: The Swiss National Foundation for the Promotion of Scientific Research at the University of Berne, and the Foundation pf Medico - Biological Fellowships of the Swiss Academy of Medical Sciences fpr their generosity in funding my research in the years 1976 - 1978, Dr. William F. Bynum for his constructive criticism of the results of my research, which guided me through the medical, social and cultural history of Georgian Britain, and for his valuable advice in matters of Organisation and style, Dr. Edwin Clarke for his continuous support during my stay in London, The entire staffs of the libraries of the British Museum, the National Maritime Museum, the Royal College of Surgeons of England, the Royal Society of Medicine, University College London and, and, above all, of the Wellcome Institute for the History of Medicine, London, and most particularly Mr. Justus Cornelius, Mr. Eric Freeman, and Mr. Robin Price, for their interest, patience and unwearied help, Dr. Vance Hall for many a valuable discussion, especially when it came to transforming the rocky abruptness of Swiss English into a steady flow of British English, Dr. Vivian Nutton for his elucidations of ancient medicine Dr. Robert Heller and Professor R. Graham G. Rüssel for their encouragement and friendship, Mrs Sheila Maltby and Mrs Hazel Pritchard for their expert typing of this thesis, And last but not least my dear wife who always creates an ideal working atmosphere. 18.10.2006 TABLE OF CONTENTS ABSTRACT 2 ACKNOWLEDGEMENTS 3 PREFACE 10 CHAPTER ONE : INTRODUCTION A. Clinical statitistics - the traditional view 14 B. The problem 18 C. Illustrations 29 D. References 32 CHAPTER TWO : THE BRITISH MEDICAL SCENE 1750 – 1830 34 A. General background 34 1. Methodological questions 34 2. New facilities: Hospitals and dispensaries 36 3. Medical societies andperiodicals 38 B. Specific background : The rise of quantification, and 40 medicine in the 17th and 18th centuries 1. "Statical" quantification, demography' and vital 40 Statistics 2. Social and preventive medicine 43 3. The weather-disease relationship 45 C. The possibilities of the "observationist" doctor 47 1. The number of observations 47 2. The analysis of observations: The Monro-Millar dispute 50 3. The "observationist" and the "arithmetic 53 observationist"doctor D. The organisation of the Army and Navy Medical Services 55 1. The Army 55 2. The Navy 61 E. On fevers F. References 18.10.2006 CHAPTER THREE I DISPENSARY AND HOSPITAL MEDICINE A. Introduction 75 B. Prelude 76 1. Francis Clifton 76 2. The Edinburgh School 78 a) Doctors Monro 78 b) William Cullen and John Gregory 80 C. Early reports from general institutions 82 1. In London 82 a) George Armstrong and the Dispensary for Sick Children 82 b) John Coakeley Lettsom and the Genral Dispensary in Aldersgate Street 82 c) John Millar and the Westminster General Dispensary 85 d) William Rowley and the St. Marylebone 90 e) William Black 92 f) The Medical Society of London 99 2. In the Provinces 100 a) John Clark at Newcastle-upon-Tyne 100 b) Thomas Percival at Manchester 104 D. Work at specialized institutions 107 1. Fever Hospitals 107 a) John Haygarth at Chester 107 b) James Currie at Liverpool 108 c) John Ferriar at Manchester 111 d) The Warrington Group 111 e) The London Fever Hospital 112 f) Irish Fever Hospitals 114 g) Scottish Fever Hospitals 116 2. Numerical investigations at Midwifery Hospitals 117 3. Evaluation of cures at Bath 125 a) Rice Charleton 125 b) William Falconer 126 E. Therapeutical trials and numerical nosography 129 1. William Withering at Stafford and Birmingham 129 18.10.2006 2. John Ferriar at Manchester 131 3. Thomas Fowler at Stafford 132 4. John Haygarth at Bath 135 F. Conclusion 138 G. References 143 CHAPTER FOUR : NAVAL MEDICINE A. Introduction 150 B. The conquest of scurvy 152 1. Scurvy as a practical issue. James Lind's observations 1753 152 2. Scurvy as a scientific problem. David Macbride's experiments 157 3. The first trials of the wort 1762 -1773 158 4. The attitude of James Lind 1772 164 5. The second voyage of James Cook 1772-1775 166 6. The American War: Robert Robertson's and Gilbert Blane's returns 167 7. The conquest of scurvy 1795 170 C. Fevers 171 1. Introduction 171 2. James Lind 171 3. Robert Robertson 174 D. The spread of the scientific use of returns 179 1. Gilbert Blane and official returns 179 a) In active naval service 179 b) In a civilian hospital 182 c) General interest in statistics 185 d) A brilliant career 186 2. Carmichael Smyth 188 3. Thomas Trotter and Leonard Gillespie 189 4. A new textbook and new regulations for naval surgeons 190 E. Conclusion 192 F. References 193 18.10.2006 CHAPTER FIVE : ARMY MEDICINE A. Introduction 197 B. The setting of the stage 197 1. George Cleghorn and William Hillary 197 2. John Pringle e 201 3. Contemporaries and followers 206 C. The treatment of fever 1750-1790 208 1. The Seven Years' War 208 2. The West Indian Campaigns 208 a) John Hume 209 b) John Hollo 210 c) John Hunter of Jamaica 211 d) Benjamin Moseley 212 e) Two pupils of John Millar : Thomas Dickson Reide and John Marshall 213 3. John Millar 215 D. More general use of the returns during the Revolutionary and Napoleonic Wars 221 1. Thomas Clark and the new regulations for regimental surgeons 221 2. James McGrigor 223 E. The treatment of fevers 1791-1815 226 1. Typhus 226 2. Yellow fever 227 a) Robert Jackson and Colin Chisholm 227 b) William Lempriere 232 c) William Wright 233 d) Edward Nathaniel Bancroft 234 e) A further group of Edinburgh trained Army surgeons 235 f) A group of East India Company surgeons 236 g) Two knights: James Fellowes and William Burnett237 3. Appendix : Ophthalmia 239 4. Recapitulation 240 F. The aftermath of war, 1815-1830 240 1. The treatment of fevers l8l6-1830 240 18.10.2006 2. Syphilis 243 G. General development and Conclusion 247 H. References 251 CHAPTER SIX I LITHOTOMY A. Introduction 256 1. General remarks on surgery 256 2. Lithotomy up to 1700 257 B. Innovations around 1700 260 1. Friar Jaques Beaulieu 260 2. William Cheselden 264 C. The influence of Cheselden in 18th century Europe 267 1. Sauveur-Francois Morand: The rotating platform in Paris 267 2. The proliferation of technical modifications up to 1800 271 3. Analytical reviews around 1800 274 D. The Norwich School of Lithotomy 276 1. The background 276 2. Matthew Dobson in the l8th century 277 3. The years 1817-1823 279 E. The appearance of lithotrity in 1824 283 1. Jean Civiale in Paris 283 2. The treatment of bladder-stone after 1824 in Britain 283 3. The introduction of lithotrity into Britain 286 F. Conclusion 287 G. References 290 CHAPTER SEVEN : AMPUTATION A. Introduction 293 1. The indications for amputation until about 1750 293 B. The main topics 1750-1790 296 1.