Book Review: To Improve the Evidence of Medicine: The 18th Century British Origins of a Critical Approach
Authors: Martin R Howard
Journal: Journal of the Royal Society of Medicine (2001)

Ulrich Trohler's thesis is that a quantitative and critical approach to medicine did not originate in Paris in the first half of the nineteenth century, as is generally believed, but was first fostered in Britain in the second half of the eighteenth century. At this time several British doctors perceived the need for adequate empirical evaluation of existing and proposed treatments. They understood that the way forward was a rejection of the traditional dependence on dogma and complex pathophysiological theories of disease and instead a reliance on comparative trials with the results expressed as numbers—something they referred to as `medical arithmetic'.

With its roots in a PhD written over twenty years ago the book finally brings Trohler's valuable and fascinating research to a wide audience. It is broadly divided into three parts. In the first there is an overview of the state of British medicine in the eighteenth century and an explanation of the intellectual and structural elements which allowed the new arithmetic approach to be applied. The intellectual basis was essentially the emergence of a climate of `rational empiricism', a general emphasis on observation rather than theory, and also the profusion of medical societies allowing these views to be propagated. The structural change was the increased dependence on institutionalized medical treatment in hospitals and dispensaries and in the armed forces which permitted adequate numbers of cases to be collected together to use the new methods.

The second and largest part is the exploration of contemporary health issues to illustrate Trohler's theory. Trohler states that this presentation is for a general readership and undoubtedly it provides both a vivid insight into the medical practice of the period and a cogent argument for a British origin for quantitative evaluation. The subjects addressed are the management of fever (the `cancer' of the eighteenth century), surgery for bladder stones, the treatment and prevention of scurvy, digitalis in dropsy, the use of spa waters for rheumatic disorders, amputation for limb injuries in war and the control of syphilis and ophthalmia in the army. Even the very familiar, such as Lind's work in scurvy and Withering's in dropsy, are reinvigorated by Trohler's exhaustive research.

In the third and final part the major findings are summarized. There is discussion of the type of men who invented this new medicine—often outside the mainstream, `dissenting' in nature, and from a military or provincial background with Scottish connections. The immediate impact of `medical arithmetic' on day-to-day practice and the ethical issues it raised about experimenting on patients are addressed. Most significantly, Trohler draws striking parallels between the eighteenth and early nineteenth century work of the `arithmetic observationists and experimentalists' and ongoing developments in the second half of the twentieth and early twenty-first centuries. One is repeatedly impressed by the apparent modernity of the methods used by these pioneers of evidence-based medicine.

I have no serious criticisms. The title is a direct quote from the eighteenth century but perhaps the book deserved something more inspiring. On occasion Trohler's `rocky Swiss English' (his own words) has evaded the editors. This is a scholarly and entertaining work. The author argues his case lucidly with a profusion of historical detail which is thoroughly referenced. The Royal College of Physicians of Edinburgh have produced it very nicely in softback format with pleasing illustrations and at a surprisingly reasonable price. I strongly recommend it to all those with an interest in the history or future of British medicine.