18 Medical Quantification: Science, Regulation, and the State THEODORE M. PORTER Amador spoke doe ale cle Médecine in Paris city fo adapt treatments to 1 of their p) Medical Quantification 395 STATE AND STATISTICS The Greek heritage claimed by the European medical tradition pro- Vided also a basis for regarding patients collectively. Medicine was ial science ~ a “science de homie” ~ that classified disease to customs and temperaments. The Hippocratic text on 1 Places” explained how sickness was related to geog- raphy and climate, This was put forth in the guise of instructions for doctors working at a new location, to inform them of what diseases to, expect there. But these environmental doctrines came increasingly bbe valued as the basis for publichealth measures. In the seventeenth century, when states began to collect numbers about causes of death, ‘organized medicine was able to draw on familiar causes and categories to explain the results Jolin Graunt’s treatise of 1662 on the London bills of mortality pro- vided a model for how to present the new statistics and judge thei ificance. Natural history, 100, was becoming increasingly quantita des Sciences, and of doctors formed to assemble in qu experience and (0 assess the effectiveriess of against smallpox ~ a controversial issue that aroused great provoked public controversy through much of the eighteen ‘which was debated by mathematicians such as Daniel Bernoulli and Jean D’Alembert.* | in this last discussion, Bernoulli deployed numbers ns to defend the ty of ion from the _ le d’Alembert doubted if the tendency of mortality tables could outweigh the tender caution of a father or mother faced with a choice that might lead to the immediate death of a beloved child, Not for nothing did this aspect of health come nineteenth century to bear the name of statistics (i. state descriptive science of the state. guidance of public interventi ple about the condi governments. The demic diseas ‘area of public he“Theodore M. Porter was extended also to diseases of the social body, -e, For many nineteenth-cen- as often require the retreat the attempt to regulate in regard, for instance, to ineteenth-century reformers often supposed ygiine publiqu Ineing crime, pauperism, and i Insurance against pansion of med ical statistics in the eighteenth and nineteenth centuries, then, is not simply synonymous with ye state, Te was, however, ic action and soci mt the statistical movements that became so active in North America beginning in the 18208, Along with these efforts 10 redefine the role of statistics entailed also a new form of knowledge. German academic sta oped an appro istical_ me ans of the minology for ngen) — which required stance, however, they were followers of the Belgian Adolpbe Qu cl his Engl astonishing collective regularity of suicide, chat seemed very far from ord Epidemics were not stable in the same way, normal patterns of disease and death. Fe however, they had their own distinctive pattern of on which i tive order of society, a special first influential form of medical th by age as su ies depended. This faith in a c form of human science, underlay d quantification." SCIENCE AND MEASUREMENT regarded as more art than seience, it was crsities, in part through instruc ing. Doctoring was about skill and judg: as formal learning, and the medical sciences, fa dissolving this art into them, were in nate to medicine as a profession. Medical knowledge meant skill in ntexpreting signs, rather than, as modern doctrines of evidence-based any ways «only a moclest place up the period of the Enlightenment, ims of medical science began to gain in effectiveness ane te eighteenth century. The hospital orthodox medicine entific medicine and also, a8 in Paris, a place to study di phenomenon. Un hed institutions did not often aspire to explanation in terms of get eral laws, and the biological vitalism of the late eighteenth century ined pervasive. Such doc Ne with the h of many practitioners in the ineffable medical touch. Physicians associated diem with doubts regarding mumbers and measures, anc sometimes also about medical instruments. A fever was much more than a thermometer reading, just as the pulse did not reduce (0 = heart rate. fe was singularly porate mea traditions and absorb the extraneous ideals of astronomy or physics The role of measurement in most of science was 4 the late eighteenth century. Physies took par sion of quant 1750, ut it wasn: forefront, Land surveys, accounts, and population sta ws great a role in the new quantitative enthusiasm as did exper -health statistics were part of the same move al method of P.C.A. Louis, against which Risueric ’Amadior inveighed, involved statistics on the scale of a great Paris hospital, yet depended on experiment and not on censuses ot surveys. It would be more accurate to say that medicine participated in the ication of science, rather than that it imitated or resisted an nent of statistical medicine Claude Bernard was a pioneer of a nen ‘of experimental precision in physiology, and su teristic of nineteenth-century scies . His great campaign was precisel domain of medical art and to replace it with science. th ind he was an unflagging champion of what he called experimental determinism, The point was not to detect308 ‘Theodore M, Porter Jose correlations but {o comprehend causes, in an effort to explain tappens not most of the time, but every time. ine accelerate 1¢ remains the laboratory sc .teriology: In the biomedical is had more to do with proce 1e understanding of physiological processes was physiology did not put wh laboratory experiments as well as therape Complaining nthe 1o4os of medical experiinentalss who put their takin an sperimenton eres rather than performing enough tials on sto comprehend the ae INSURANCE AND REGULATION oratory. The enormously ver the eth century reflects an evercloser 1 laboratories. The emer important part of the at work, . in the sense of neutral indicators or measures that could tition . a Medical Quantification, 300 supposed essential ro not lie no mattei 1 this story.” Since the late nineteenth century, insurance institutions have been central to the movement towards a more colleetivized form of medi= cine. For a time, life insurance was as important in this respect as heal in the early twent- ations provided as much as 12 per cent of the income of doctors. Young physicians, just starting out, were ly dependent on such work while they tried to build up a base of patients. In part because they needed to attract and hold nev what interests were at stake, plays an Is, and also of the salesmen who stood to reap a generous ission if the insurance policy should be issued. These insurance agents, whose persistence and resourcefulness became legendary, Is. Few people apply on their on initiative for life insurance, and those who do as likely to be bad risks. One key to the suic- (o the actuaries and other professionals who tun them, is to avoid the “adverse selection” that came from admitting a substandard popul medical directors of eatly-twen determining a proper rate for new customers, found it extreme! honest and informed evaluation of the health of apy Faced with so diffi em of ust, medical directors, came increasingly to favour objective criteria, such as the relationship of height and wei id they developed tables based on thei own measures to mortality rates. In the eatly companies collected linking, elevated blood pressure (*hypertension") to health risks, and they were early advocates of electrocardiograms and xrays for prognostic purposes. “Modern” medical practitioners, they thought, should have such equipment in their offices, and in this way they helped to define such instruments as a basic feature of modern medicine.” Most of the “basic” medical sciences of the twentieth century, right up to the present, have not been particularly quantitative ones. This is especially true of molecular biology, which for about three decades now has been regarded by many as vir another modernism, “modern” biology, Systematic quar and rigorous statistical testing have been more prominent in applied. aspects of medicine, especially in the design and analysis of thera- peutic trials. Such methods are often powerful and effective, andTheodore M. Porter 1, have a compel readings, laboratory tests, and contr medicine by taking part in a sweeping cultural internal 10 medic to the extent possible ey reduce the exposure of med- ical climate, at least that seems to go against sti iioner ively unconst jon and oversight and ey and st converting the uncer that pervade life into. numbers is ‘a state of nature, without elaborate infrastructures and compiling data, and such reasoning to untutored modes of ssional interes by a remarkable flourishing of and the modes of cal central 0 medical practice. ig 4 subs cant, oF more consequent pistemology, I would snggest, is becom and this is nowhere more signi jan in medicine, Medical Quanti ion gon NOTES 1 Andrea Rusnock, Vial Acraunsas Quantifing Health and Population im Bigh- t-Contury England and Prance (Cambridge: Cambridge University , Death Isa Social Diseases Public Health and Political iy Industral Bronce (Madison: University of Wiscons is Ewald, LBtal providence (Paris: Bernard Grassi The Rie of Statsivnl Thinking, 1820-1900 (Prince Press, 1986); Jan Hacking, The Taming of nex (Cambrielge: Cambridge University Press. 1990) sand Robin Rider, eds, Nhe Quantifing Spit in the Eighteenth Ceniury (Berkeley: ¥ of California Press, 1990) 5 J. Rosser Matthews, Qué nceton, Xf: Princeton. 6 Major Greenwood, Authority in Moiicne: Old and Naw (Cambridge: Came Pres, for Mediead Contains ‘Theodore M. Porter, Kav! (Pearson: The Scent (Princeton, xj: Princeton University Press, 2004). wh: Wissenschaft wn Alltag des Fier: ‘messens (Pranklurt: Campus, 2000); John Harley Warner, The Therapeu Parspeti: Medical Practice, Knxledge, and Identity x America, 1820-188 ridge, Mass: Harvard University Press, 1986); Theodore M. Numbers: The Pursuit of Objeicity in Science and Public Life iy: Princeton University Press, 1995 i 8 Theodore M, Porter, “Life Insurance, Medical Testing, and the Manage- 1 Daston, ed. Biagraphies of Scientific Objets ‘of Chicago Press, 2000), 226-46. (9 Harry M, Marks, The Prgnss of Experiment: Science and Therapeutic Reform in ‘he Cnited Stats, 1900~1990 (Cambridge: Cambriege University Press, 1997) Life im a Satistical Age 5 : 3 1c, TrustWHEN EXPERIMENTS TRAVEL ADRIANA PETRYNABody Counts Medical Quantification in Historical and Sociological Perspective / La quantification medicale, perspectives historiques et sociologiques EDITED BY GERARD JORLAND, ANNICK OPINEL, AND GEORGE WEISZ