- Email: [email protected]
APPENDIX TO THE Lectures ON LITHOTOMY AND LITHOTRITY.
JANUARY 22, 1853. APPENDIX TO THE
Lectures ON
LITHOTOMY AND LITHOTRITY. Delivered at St.
BY WILLIAM
Mary’s Hospital.
COULSON, ESQ.,
SURGEON TO THE HOSPITAL.
THE STATISTICS
OF
LITHOTOMY
AND
LITHOTRITY.
IN the parallel which I have drawn, lithotomy and lithotrity have been compared in a general manner; but this is not sufficient to determine the intrinsic value of each operation considered as I have still to examine their results, when a means of cure. in applied practice-the only true test by which they can be estimated. It has been said that little reliance can be placed on statistical deductions from a number of operations performed by different surgeons, in countries far distant from each other, under a great variety of circumstances and influences, which prevent any one series of cases from possessing the same value as another series of equal number. This remark has a certain of weight, but it is no valid reason for rejecting statistics altogether ; it only shows that they are not entirely faultless ; and what branch of medicine—I might almost add, of human knowledge-is free
degree
from this reproach ? Our statistics are not perfect, because no two cases, and therefore no two series of cases, are perfectly identical in every respect, as are two lines or two angles. We cannot arrive at mathematical certainty; but when all the essential points of any given number of cases have been properly ascertained, the value of disturbing influences can be estimated, the elements of resemblance or analogy can be fixed, and from these a great number of useful deductions can be drawn, just as the probable duration of human life in any given case can be fixed from deductions made from a consideration of numerous cases which are anything The above table gives us a sum-total of 6369 operations, more than two-thirds of which have been performed since the combut identical. I will not now dwell on the several conditions necessary for mencement of the present century. The number of deaths was and the general mortality is therefore 1 in 6-62 cases. formingagood statistical résurmé, and shall merely observe that 958, The returns from the Luneville Hospital have been published one of the most essential is what has been called " the law of numbers." The greater the number of cases on which we by M, Castara; those from Moscow by Dr. Roos, of St. Petersoperate, the less likely are our deductions to be weakened by burgh ; those marked with an asterisk by M. Civiale, in his work various sources of error, to which conclusions from limited num- on Calculous Diseases. The sources from which I have derived bers are exposed. This remark applies in particular to lithotomy. the other returns are familiar to most surgeons. The cases, I need hardly say, have not been selected, but all While explaining the accidents of that operation, I showed how which presented a sufficient degree of authenticity were many of them depend on influences beyond the control of the those without other distinction. operator, and were developed under circumstances for which it admitted The mortality in the English cases, 1743 in number, is nearly is difficult or even impossible to account. Hence great success 1 in 7; the 251 deaths give a proportion of one death in 6-93 may appear to attend the operation, when applied to a limited number of cases; but let the number be increased to any extent, cases, which is a very favourable result. M. Civiale’s work on Calculous Diseases contains a great and the causes alluded to come into play. number of valuable tables, in the collection of which the author in is familiar with this fact. extensive Every surgeon practice Ten, twenty, thirty cases may succeed without interruption, and was assisted by returns forwarded to him from the principal The first table (page 550) contains a the operator flatters himself that he is never to lose a patient, when hospitals of Europe. two or three deaths follow in quick succession, and reduce him to a summary of 3991 operations of lithotomy ; but it is impossible to level with his neighbours ; or at least within the limits of varia- make it available for my present object, because the results of tion which the analysis of a large number of cases indicates. lithotrity are mind up with those of lirhotomy. Another table (p. 582) contains a summary of 2368 operations The examples mentioned by Mr. Liston and Mr. Crosse will illustrate this point. Mr. Liston states that all the patients performed in France since 1738 ; the number of deaths is 374. submitted to lithotomy in University College Hospital for a It is necessary, however, to deduct the cases of lithotrity, and period of six successive years-and they were 24 in number- correct an error, M. Civiale having set down the deaths at from two to eighty years of age, recovered. Mr. Crosse records Luneville as 150, whereas they were only 141. With these corrections, I find a total of 2054 cases and 357 that 38 patients successively operated on in the Norwich Hospital (previous to November, 1834), by Mr. Dalrymple, Lllr. Norgate, deaths, being a proport’on of 1 in 5.75. It should be observed that this table embraces the results of and himself, recovered. all the various modes of lithotomy; the apparatus major, These are splendid results, highly creditable to English surbilateral, recto-vesical, and high operations, are comprised in gery ; but it is manifest that from so limited a number of cases table. Besides, a portion of the cases in " private practice," no correct estimate can be formed of the general mortality of the can , hardly be admitted as showing the real statistics of lithotomy ; lithotomy. The only mode of arriving at a proximate result is to collect ’
,
nearly
the
as great a number of properly-authenticated cases as and this I have endeavoured to do in the following table:-
possible,;
No. 1534.
* The returns from localities marked (*) have been taken from M. Civiale’s Tables. t Traite de l’Affection Calculeuse. Paris, 1838. E
72 for it would prove, according to M. Civiale, that 106 patients were lost out of 190 operated on by the b estsurgeons in Paris, between the years 1824 and 1835. I have therefore endeavoured toform another estimate of the results of the lateral operation in France ; but the number of cases is rather limited. The elements are derived from M. Civiale’s work. P,e,3ztlts of the Lateral Operation in France.
A great increase in the number of cases does not, however, alter the proportion much. Thus, if we take from M. Civiale’s Table (p. 682) the cases of lateral operation performed in various parts of Europe, we haveDeaths. No. of Cases. Proportion. 1 in 5-14 2278 ......... 443 .........
Our returns are not included in this table. have the following result :--
If
we
add them
we
According to M. Civiale’s mode of calculating, the proportion of mortality, derived from his table given above, would be 1 in 4-92, instead of 1 in 514. This difference is explained by the peculiar process which M. Civiale has adopted for establishing his proportions. He rejects all incomplete cases, and all those in which the cure has not been perfect; yet he retains the whole number of deaths. This method shows correctly the proportion of cures to the number of cases, but it is evidently erroneous when applied to In a limited number of cases it an estimate of the mortality. might increase the relative mortality from one in four to one in three, that is to say, more than eight per cent. Having thus proved that the general mortality of lithotomy, taken from a large number of cases, (6366,) is 1 in 6’64, it becomes necessary to enter into particulars, and show how the proportion of deaths may vary under particular circumstances. The principal causes of death after the operation have been already explained, and I have shown that the chances of recovery will be considerably modified by the size of the stone, the condition of the genito-urinary organs, and the tendency to the development of those inflammatory affections from which so many patients die. The probability of a fatal result is increased in proportion to the size of the stone, the diseased state of the organs, and the tendency to inflammation. In early life the influence of these conditions is much less than at later periods. The deposit of calculous matter generally takes place in a slow manner; the longer the foreign body has been present in the bladder the more likely it is to excite disease ; and young subjects are less liable to inflammation of the bladder or kidneyss than adults and aged persons. Hence we may anticipate that the mortality of the operation when performed on children, will be much below the general average; and statistics prove this to be the case in all countries and under every method. The table in the next column places this fact in a very clear light. The elements of this table have not been selected. I have taken all the series of cases in which the ages are distinguished into decennial periods, and which from their number offer some guarantee against disturbing influences. The total number of cases (2972) is considerable, and a glance at the table shows two important facts—viz. that the number of patients submitted to lithotomy decreases with each decennial period of life, and that the mortality increases at each successive period. Thus below 10 years it is 1 in 13, and thence gradually augments from 10 to 80 years to 1 in 9, 1 in 6, 1 in 5, 1 in 4, 1 in 365, 1 in 3-23, 1 in 2.71.
73
Notwithstanding the favourable results obtained at the Hotel Dieu and the Norwich Hospital, those of Cheselden and the surgeons of St. Thomas’s Hospital scand out in extraordinary relief. Cheselden lost only 1 patient out of 3.5 under ten years; while at St. Thomas’s Hospital, during a period of 23 years, the mortality at the same period of life was only 1 in 58. This perhaps is the most brilliant success of which modern surgery can boast; and I cannot but congratulate my esteemed fbend, Mr. South, for having
afforded us,
Influence of Weight of Calculus
on Results From Mr. CROSSE.
of Lithotomy.
of the tables in his transof establishing it.
by the publication
lation of Chelius’ Surgery, the
means
St. 7Wontas’s Table. 144 Cases in
all; in
19
no
age
given-1
in
9 o.
Weights of
Age not given for
one
Calculus in One Hundred Patal Cases. From Mr. CROSSE.
death.
From 60, and 60 to 70, the relative mortality appears to Oe very nearly the same; the difference in favour of the former 50 to
365 to 323. Beyond 70 the deduction can be safely drawn from them. On the 12th of December, 1852, I extracted a calculus from the bladder of a patient in his eighty-first year. Re has recovered; and there are but few successful cases so old on record. The following table of the deaths after lithotomy according to age is taken from M. Civiale ; but I have arranged it in a somewhat different manner :-
period being
a mere
fraction,
or as
number of cases is so small, that
Table
no
of Deaths ctfte2- Lithotomy according to Ages, from M. CIVIALE.
The proportion of deaths at the different periods of life is much greater than that indicated in my own table-a circumstance which may perhaps be explained by what I have already said relative to M. Civiale’s method of calculating the from the cases of perfect cure only. In another table (page 680), which is said to be taken from statistical returns of a more recent date, the mortality is still higher. M. Civiale calculates it at 1 in 4’63 for children up to the age of 14 ; at 1 in 3’64 for adults between 15 and 60 ; at 1 in 1-62 for old persons beyond 60 years of age. It is universally agreed that the size of the calculus exercises a marked influence on the result of lithotomy. Calculi of large size cannot be extracted by the lateral operation without great risk of life, and the other methods present results which are not much more favourable. The size of the calculus cannot be correctly estimated from its weight, though it may approximatively. The only statistical returns which we possess on this point are due to the late Mr. Crosse, from whose essay valuable information may be derived on nearly everything connected with the history of urinary calculi. Mr. Crosse weighed all the calculi in the Norwich collection, and having compared the weights with the registered results of each case, drew up the following tables :-
The above returns are highly instructive. They show how is the occurrence of a calculus weighing more than 4 or 5 ounces ; and, on the other hand, they indicate the influence which the size of the stone exercises on the result of the operation, the mortality increasing in nearly the same ratio as the weight. Seventy-five per cent. of the calculi were under one ounce in rare
weight; 17 per cent. under 2 ounces; 5 per cent. under 3 ounces; the proportion of those above 3 ounces was about 12 per cent.; the remainder a little less thanper cent. No statistical records exist which throw any light on the causes of death after lithotomv. This is a strange omission, not easily to be accounted for. Even Mr. Crosse has neglected to investigate the causes of death in the 100 fatal cases for which he has given the weight of the calculi. Perhaps some of the surgeons attached to the Norwich Hospital may be induced to repair this omission. The St. Thomas’s Tables are equally defective in this point, the cause of death being indicated for a few cases only. Dupuytren is the only writer on lithotomy who has recorded the causes of death; but his results apply to the bilateral method only. The following table has been formed from his notes:-
mortality
I will not draw any conclusion from so limited a number of but I cannot avoid directing attention to the fact which seems to be indicated by the last element-viz. the frequency of death from inflammation of the cellular tissue of the pelvis. Out of the 19 deaths, 7 occurred from this cause.
dissections;
74 In the parallel which I have drawn between the various methods of lithotomy, I endeavoured to discuss the merits and demerits of each in an impartial manner. To complete this part of the subject, I have drawn up a few tables of the mortality of lithotomy according to the methods employed.
MORTALITY
AFTER
Mortality of Lithotomy according to the Method employed.
LITHOTOMY.
Apparatus Major.
Morand, " Trait6 de la Taille" and " Opuscules de Chirurgie."
*
t Mr. Humphry, Addenbrooke’s Hospital, Cambridge.
I
Here Cheselden’s
operation,
as
might
be
expected, stands
at the head of all. The mortality in more than 2000 cases was 1 in 7’38. The apparatus major comes next, a result for which I confess that I was not prepared. In nearly 2000 The recto-vesical follows cases the mortality was 1 in 4’89. close on the apparatus major, giving a proportion of 1 in 4.87
t
Report from Professor Eve,
of Nashville
University, United States.
Then comes Dupuytren’s bilateral operation, with a mortality of 1 in 4 ; and finally the high operation, which in 268 cases gives a mortality of 1 in 308. The frequency of urinary calculus at the different periods of life is a point of some interest. M. Velpeau estimates that onethird of calculous patients are children. This estimate, however, is considerably below the true one, as the following tables show:-
Frequency of
§ Reported by Dr. Gross in his work on Diseases of the Bladder: one child, aged three, died eighteen months after the operation, from disease of the kidney; and a man aged seventy-seven died six weeks after it, from apoplexy.
adding these tables to those which I have already given, following view of the mortality according to the method employed is obtained : On
the
Calculus
at
Different Ages—M.
CIVIALE.
75 From the above table it appears that 55½per cent. of calculous under twenty years of age ; and if we take the word 11 child" to mean an individual under fifteen years, we have a proportion of 4S per cent. for that period of life. My own table gives a proportion somewhat higher.
This table indicates an immense proportion of aged patients, and if the mortality he, as stated by M. Civiale, one in 42, the result is of a kind which no lithotomist can pretend to approach. M. Civiale’s statistics embraces two periods, one from 1824 to 1836, during which. 305 operations were performed; the number of deaths was 7. During the second period, from 1836 to 1846, 276 operations were performed, and the number of deaths was
,
patients are
Frequency of Calculus at Different Ages.
also 7. The first statistical publicationof M. Civiale were submitted to a committee of the Institut, composed of Larrey, Double, and Boyer, who thought they detected several omissions in them. The report presented by M. Double has frequently been referred to since then as of want of good faith on the part of M. Civiale; but M.Velpeau, and some of our English writers, have forgotten to mention that these identical statistics, together with the proofs in their supporr, were again submitted to the Institut in 1835; M.11. Larrey and Double were members of the committee to which the new documents were submitted. They reported on them, and permitted M. Civiale again to state, but this time without contradiction, that he had lost only 6 in 257 cases. This statement was subsequently printed under the authority of the Academy of Sciences, and we may therefore regard it a, correct. In the second series of cases, the mortality is set down by M. Civiale at 7 also. He does not attempt, however, to conceal the fact, that 10 other patients, on whom lithotrity had been commenced, died. These patients were not included in the general table, because the operation had not been persevered in, been found unsuited for litho. the cases after a few trials tritv. Many may be disposed to think that they should be comprised in the general table, and if this be done, we have a total of 591 operations, and 24 deaths, or 1 in 24: a result with which the most sanguine advocates of the method may be content. Lithotrity has been frequently performed in France by MM. Leroy d’Etiolles, Heurteloup, and Amussat, but they have not published a complete account of their cases. Of those given by M. Leroy, we find 11 deaths in 116, while M. Heurteloup asserts that he lost only 1 patient in 38. Of the first 112 operations performed in Italy, 9 proved fatal. Professor Campanella sta’es that 10 patients were treated by lithotrity in the hospital of Loretto between 1834 and 1839, and all recovered. Seven of them were above 40 years of age.* In the following table the results of lithotomy and lithotrity
proof
In
drawing
table, I have added Mr. Liston’s cases, and Infirmary, to the cases given in a former were cases submitted to operation. Those in
up this
those from the Leeds table. The whole M. Civiale’s table
derived from returns which include the The difference between the two tables, derived from nearly the same sources, would seem to are
patients not operated on.
which are indicate that numbers of adult and aged patients are rejected for lithotomy. As the returns in my own table were drawn up in decennial and bicennial periods, I have not been able to determine the exact proportion of subjects under fifteen years of age. To complete the statistics, I add a short table of results obtained from private practice. I do not pretend to dispute the authenticity of these returns, having no means of forming a judgment on them, but they are for the most part evidently exceptional, and for various reasons I have not included them in the
having
general tables. Recorded Results
of Lithotomy in Private Practice.
are not
distinguished.
’
The Statistics of Lithotrity are confined to the results which M. Civiale has published of his own practice. No other surgeon who has
extensive scale has given a complete account of all the cases on which he operated. This omission is greatly to be regretted ; yet the manner in which M. Civiale’s publication was received, both in France and in other countries, was little calculated to encourage other practitioners to follow his example. I well know that the statistics of M. Civiale have been severely criticized, and that he has been openly accused of serious omissions in the several accounts published by him. I must leave the responsibility of their correctness on that distinguished surgeon, having neither time nor inclination to re-open a discussion which has now been closed for so many years, even in France. The followingis a tabular view of M. Civiale’s results :-
performed lithotrity
on an
Proportion,1 Children Adults
In this
...............
306 231 59
Total ............
596
..................
..................
OJd People
’,
in 6-43.
have contributed little or nothing to the statistics of Lithotrity. Sir Philip Crampton, and Mr. Teale, of Leeds, are the only surgeons who have published an account of the whole of the cases which occurred to them. In this particular they merit praise, but no conclusion can be drawn from their limited number of cases ; and I say this with great respect for these excellent surgeons. * Repertorio di Piemonte. August, J839. + Fihatro Sebezio. July, tga9.
country
CRETINISM
we
AND
GOITRE.—A report
on
the number
of persons afflicted with cretinism or goitre, in the department of the Bas-Rhin, has just been published by Dr. Tourdes. In 1852, according to the return of medical men of the different cantons, the disease existed in 38 communes. The number of cretins in these communes was 125 ; and that of persons affected with goitre, and not idiots, 873. The causes of this disease are still to a great extent mysterious ; for there are communes free from it, and yet having the same character as others in which it most prevails. Many medical men have attributed cretinism and goitre to the water of particular localities; but Dr. Tourdes analyzed the water in communes where goitres were very prevalent, and in others where they did not exist, and discovered no difference. It appears, however, that the disease in the BasRhin is much less extensive than it was several years ago ; and the diminution coincides with the draining of the marshes, and the improvements in the cultivation of the soil. ’
Lectures ON
LITHOTOMY AND LITHOTRITY. Delivered at St.
BY WILLIAM
Mary’s Hospital.
COULSON, ESQ.,
SURGEON TO THE HOSPITAL.
THE STATISTICS
OF
LITHOTOMY
AND
LITHOTRITY.
IN the parallel which I have drawn, lithotomy and lithotrity have been compared in a general manner; but this is not sufficient to determine the intrinsic value of each operation considered as I have still to examine their results, when a means of cure. in applied practice-the only true test by which they can be estimated. It has been said that little reliance can be placed on statistical deductions from a number of operations performed by different surgeons, in countries far distant from each other, under a great variety of circumstances and influences, which prevent any one series of cases from possessing the same value as another series of equal number. This remark has a certain of weight, but it is no valid reason for rejecting statistics altogether ; it only shows that they are not entirely faultless ; and what branch of medicine—I might almost add, of human knowledge-is free
degree
from this reproach ? Our statistics are not perfect, because no two cases, and therefore no two series of cases, are perfectly identical in every respect, as are two lines or two angles. We cannot arrive at mathematical certainty; but when all the essential points of any given number of cases have been properly ascertained, the value of disturbing influences can be estimated, the elements of resemblance or analogy can be fixed, and from these a great number of useful deductions can be drawn, just as the probable duration of human life in any given case can be fixed from deductions made from a consideration of numerous cases which are anything The above table gives us a sum-total of 6369 operations, more than two-thirds of which have been performed since the combut identical. I will not now dwell on the several conditions necessary for mencement of the present century. The number of deaths was and the general mortality is therefore 1 in 6-62 cases. formingagood statistical résurmé, and shall merely observe that 958, The returns from the Luneville Hospital have been published one of the most essential is what has been called " the law of numbers." The greater the number of cases on which we by M, Castara; those from Moscow by Dr. Roos, of St. Petersoperate, the less likely are our deductions to be weakened by burgh ; those marked with an asterisk by M. Civiale, in his work various sources of error, to which conclusions from limited num- on Calculous Diseases. The sources from which I have derived bers are exposed. This remark applies in particular to lithotomy. the other returns are familiar to most surgeons. The cases, I need hardly say, have not been selected, but all While explaining the accidents of that operation, I showed how which presented a sufficient degree of authenticity were many of them depend on influences beyond the control of the those without other distinction. operator, and were developed under circumstances for which it admitted The mortality in the English cases, 1743 in number, is nearly is difficult or even impossible to account. Hence great success 1 in 7; the 251 deaths give a proportion of one death in 6-93 may appear to attend the operation, when applied to a limited number of cases; but let the number be increased to any extent, cases, which is a very favourable result. M. Civiale’s work on Calculous Diseases contains a great and the causes alluded to come into play. number of valuable tables, in the collection of which the author in is familiar with this fact. extensive Every surgeon practice Ten, twenty, thirty cases may succeed without interruption, and was assisted by returns forwarded to him from the principal The first table (page 550) contains a the operator flatters himself that he is never to lose a patient, when hospitals of Europe. two or three deaths follow in quick succession, and reduce him to a summary of 3991 operations of lithotomy ; but it is impossible to level with his neighbours ; or at least within the limits of varia- make it available for my present object, because the results of tion which the analysis of a large number of cases indicates. lithotrity are mind up with those of lirhotomy. Another table (p. 582) contains a summary of 2368 operations The examples mentioned by Mr. Liston and Mr. Crosse will illustrate this point. Mr. Liston states that all the patients performed in France since 1738 ; the number of deaths is 374. submitted to lithotomy in University College Hospital for a It is necessary, however, to deduct the cases of lithotrity, and period of six successive years-and they were 24 in number- correct an error, M. Civiale having set down the deaths at from two to eighty years of age, recovered. Mr. Crosse records Luneville as 150, whereas they were only 141. With these corrections, I find a total of 2054 cases and 357 that 38 patients successively operated on in the Norwich Hospital (previous to November, 1834), by Mr. Dalrymple, Lllr. Norgate, deaths, being a proport’on of 1 in 5.75. It should be observed that this table embraces the results of and himself, recovered. all the various modes of lithotomy; the apparatus major, These are splendid results, highly creditable to English surbilateral, recto-vesical, and high operations, are comprised in gery ; but it is manifest that from so limited a number of cases table. Besides, a portion of the cases in " private practice," no correct estimate can be formed of the general mortality of the can , hardly be admitted as showing the real statistics of lithotomy ; lithotomy. The only mode of arriving at a proximate result is to collect ’
,
nearly
the
as great a number of properly-authenticated cases as and this I have endeavoured to do in the following table:-
possible,;
No. 1534.
* The returns from localities marked (*) have been taken from M. Civiale’s Tables. t Traite de l’Affection Calculeuse. Paris, 1838. E
72 for it would prove, according to M. Civiale, that 106 patients were lost out of 190 operated on by the b estsurgeons in Paris, between the years 1824 and 1835. I have therefore endeavoured toform another estimate of the results of the lateral operation in France ; but the number of cases is rather limited. The elements are derived from M. Civiale’s work. P,e,3ztlts of the Lateral Operation in France.
A great increase in the number of cases does not, however, alter the proportion much. Thus, if we take from M. Civiale’s Table (p. 682) the cases of lateral operation performed in various parts of Europe, we haveDeaths. No. of Cases. Proportion. 1 in 5-14 2278 ......... 443 .........
Our returns are not included in this table. have the following result :--
If
we
add them
we
According to M. Civiale’s mode of calculating, the proportion of mortality, derived from his table given above, would be 1 in 4-92, instead of 1 in 514. This difference is explained by the peculiar process which M. Civiale has adopted for establishing his proportions. He rejects all incomplete cases, and all those in which the cure has not been perfect; yet he retains the whole number of deaths. This method shows correctly the proportion of cures to the number of cases, but it is evidently erroneous when applied to In a limited number of cases it an estimate of the mortality. might increase the relative mortality from one in four to one in three, that is to say, more than eight per cent. Having thus proved that the general mortality of lithotomy, taken from a large number of cases, (6366,) is 1 in 6’64, it becomes necessary to enter into particulars, and show how the proportion of deaths may vary under particular circumstances. The principal causes of death after the operation have been already explained, and I have shown that the chances of recovery will be considerably modified by the size of the stone, the condition of the genito-urinary organs, and the tendency to the development of those inflammatory affections from which so many patients die. The probability of a fatal result is increased in proportion to the size of the stone, the diseased state of the organs, and the tendency to inflammation. In early life the influence of these conditions is much less than at later periods. The deposit of calculous matter generally takes place in a slow manner; the longer the foreign body has been present in the bladder the more likely it is to excite disease ; and young subjects are less liable to inflammation of the bladder or kidneyss than adults and aged persons. Hence we may anticipate that the mortality of the operation when performed on children, will be much below the general average; and statistics prove this to be the case in all countries and under every method. The table in the next column places this fact in a very clear light. The elements of this table have not been selected. I have taken all the series of cases in which the ages are distinguished into decennial periods, and which from their number offer some guarantee against disturbing influences. The total number of cases (2972) is considerable, and a glance at the table shows two important facts—viz. that the number of patients submitted to lithotomy decreases with each decennial period of life, and that the mortality increases at each successive period. Thus below 10 years it is 1 in 13, and thence gradually augments from 10 to 80 years to 1 in 9, 1 in 6, 1 in 5, 1 in 4, 1 in 365, 1 in 3-23, 1 in 2.71.
73
Notwithstanding the favourable results obtained at the Hotel Dieu and the Norwich Hospital, those of Cheselden and the surgeons of St. Thomas’s Hospital scand out in extraordinary relief. Cheselden lost only 1 patient out of 3.5 under ten years; while at St. Thomas’s Hospital, during a period of 23 years, the mortality at the same period of life was only 1 in 58. This perhaps is the most brilliant success of which modern surgery can boast; and I cannot but congratulate my esteemed fbend, Mr. South, for having
afforded us,
Influence of Weight of Calculus
on Results From Mr. CROSSE.
of Lithotomy.
of the tables in his transof establishing it.
by the publication
lation of Chelius’ Surgery, the
means
St. 7Wontas’s Table. 144 Cases in
all; in
19
no
age
given-1
in
9 o.
Weights of
Age not given for
one
Calculus in One Hundred Patal Cases. From Mr. CROSSE.
death.
From 60, and 60 to 70, the relative mortality appears to Oe very nearly the same; the difference in favour of the former 50 to
365 to 323. Beyond 70 the deduction can be safely drawn from them. On the 12th of December, 1852, I extracted a calculus from the bladder of a patient in his eighty-first year. Re has recovered; and there are but few successful cases so old on record. The following table of the deaths after lithotomy according to age is taken from M. Civiale ; but I have arranged it in a somewhat different manner :-
period being
a mere
fraction,
or as
number of cases is so small, that
Table
no
of Deaths ctfte2- Lithotomy according to Ages, from M. CIVIALE.
The proportion of deaths at the different periods of life is much greater than that indicated in my own table-a circumstance which may perhaps be explained by what I have already said relative to M. Civiale’s method of calculating the from the cases of perfect cure only. In another table (page 680), which is said to be taken from statistical returns of a more recent date, the mortality is still higher. M. Civiale calculates it at 1 in 4’63 for children up to the age of 14 ; at 1 in 3’64 for adults between 15 and 60 ; at 1 in 1-62 for old persons beyond 60 years of age. It is universally agreed that the size of the calculus exercises a marked influence on the result of lithotomy. Calculi of large size cannot be extracted by the lateral operation without great risk of life, and the other methods present results which are not much more favourable. The size of the calculus cannot be correctly estimated from its weight, though it may approximatively. The only statistical returns which we possess on this point are due to the late Mr. Crosse, from whose essay valuable information may be derived on nearly everything connected with the history of urinary calculi. Mr. Crosse weighed all the calculi in the Norwich collection, and having compared the weights with the registered results of each case, drew up the following tables :-
The above returns are highly instructive. They show how is the occurrence of a calculus weighing more than 4 or 5 ounces ; and, on the other hand, they indicate the influence which the size of the stone exercises on the result of the operation, the mortality increasing in nearly the same ratio as the weight. Seventy-five per cent. of the calculi were under one ounce in rare
weight; 17 per cent. under 2 ounces; 5 per cent. under 3 ounces; the proportion of those above 3 ounces was about 12 per cent.; the remainder a little less thanper cent. No statistical records exist which throw any light on the causes of death after lithotomv. This is a strange omission, not easily to be accounted for. Even Mr. Crosse has neglected to investigate the causes of death in the 100 fatal cases for which he has given the weight of the calculi. Perhaps some of the surgeons attached to the Norwich Hospital may be induced to repair this omission. The St. Thomas’s Tables are equally defective in this point, the cause of death being indicated for a few cases only. Dupuytren is the only writer on lithotomy who has recorded the causes of death; but his results apply to the bilateral method only. The following table has been formed from his notes:-
mortality
I will not draw any conclusion from so limited a number of but I cannot avoid directing attention to the fact which seems to be indicated by the last element-viz. the frequency of death from inflammation of the cellular tissue of the pelvis. Out of the 19 deaths, 7 occurred from this cause.
dissections;
74 In the parallel which I have drawn between the various methods of lithotomy, I endeavoured to discuss the merits and demerits of each in an impartial manner. To complete this part of the subject, I have drawn up a few tables of the mortality of lithotomy according to the methods employed.
MORTALITY
AFTER
Mortality of Lithotomy according to the Method employed.
LITHOTOMY.
Apparatus Major.
Morand, " Trait6 de la Taille" and " Opuscules de Chirurgie."
*
t Mr. Humphry, Addenbrooke’s Hospital, Cambridge.
I
Here Cheselden’s
operation,
as
might
be
expected, stands
at the head of all. The mortality in more than 2000 cases was 1 in 7’38. The apparatus major comes next, a result for which I confess that I was not prepared. In nearly 2000 The recto-vesical follows cases the mortality was 1 in 4’89. close on the apparatus major, giving a proportion of 1 in 4.87
t
Report from Professor Eve,
of Nashville
University, United States.
Then comes Dupuytren’s bilateral operation, with a mortality of 1 in 4 ; and finally the high operation, which in 268 cases gives a mortality of 1 in 308. The frequency of urinary calculus at the different periods of life is a point of some interest. M. Velpeau estimates that onethird of calculous patients are children. This estimate, however, is considerably below the true one, as the following tables show:-
Frequency of
§ Reported by Dr. Gross in his work on Diseases of the Bladder: one child, aged three, died eighteen months after the operation, from disease of the kidney; and a man aged seventy-seven died six weeks after it, from apoplexy.
adding these tables to those which I have already given, following view of the mortality according to the method employed is obtained : On
the
Calculus
at
Different Ages—M.
CIVIALE.
75 From the above table it appears that 55½per cent. of calculous under twenty years of age ; and if we take the word 11 child" to mean an individual under fifteen years, we have a proportion of 4S per cent. for that period of life. My own table gives a proportion somewhat higher.
This table indicates an immense proportion of aged patients, and if the mortality he, as stated by M. Civiale, one in 42, the result is of a kind which no lithotomist can pretend to approach. M. Civiale’s statistics embraces two periods, one from 1824 to 1836, during which. 305 operations were performed; the number of deaths was 7. During the second period, from 1836 to 1846, 276 operations were performed, and the number of deaths was
,
patients are
Frequency of Calculus at Different Ages.
also 7. The first statistical publicationof M. Civiale were submitted to a committee of the Institut, composed of Larrey, Double, and Boyer, who thought they detected several omissions in them. The report presented by M. Double has frequently been referred to since then as of want of good faith on the part of M. Civiale; but M.Velpeau, and some of our English writers, have forgotten to mention that these identical statistics, together with the proofs in their supporr, were again submitted to the Institut in 1835; M.11. Larrey and Double were members of the committee to which the new documents were submitted. They reported on them, and permitted M. Civiale again to state, but this time without contradiction, that he had lost only 6 in 257 cases. This statement was subsequently printed under the authority of the Academy of Sciences, and we may therefore regard it a, correct. In the second series of cases, the mortality is set down by M. Civiale at 7 also. He does not attempt, however, to conceal the fact, that 10 other patients, on whom lithotrity had been commenced, died. These patients were not included in the general table, because the operation had not been persevered in, been found unsuited for litho. the cases after a few trials tritv. Many may be disposed to think that they should be comprised in the general table, and if this be done, we have a total of 591 operations, and 24 deaths, or 1 in 24: a result with which the most sanguine advocates of the method may be content. Lithotrity has been frequently performed in France by MM. Leroy d’Etiolles, Heurteloup, and Amussat, but they have not published a complete account of their cases. Of those given by M. Leroy, we find 11 deaths in 116, while M. Heurteloup asserts that he lost only 1 patient in 38. Of the first 112 operations performed in Italy, 9 proved fatal. Professor Campanella sta’es that 10 patients were treated by lithotrity in the hospital of Loretto between 1834 and 1839, and all recovered. Seven of them were above 40 years of age.* In the following table the results of lithotomy and lithotrity
proof
In
drawing
table, I have added Mr. Liston’s cases, and Infirmary, to the cases given in a former were cases submitted to operation. Those in
up this
those from the Leeds table. The whole M. Civiale’s table
derived from returns which include the The difference between the two tables, derived from nearly the same sources, would seem to are
patients not operated on.
which are indicate that numbers of adult and aged patients are rejected for lithotomy. As the returns in my own table were drawn up in decennial and bicennial periods, I have not been able to determine the exact proportion of subjects under fifteen years of age. To complete the statistics, I add a short table of results obtained from private practice. I do not pretend to dispute the authenticity of these returns, having no means of forming a judgment on them, but they are for the most part evidently exceptional, and for various reasons I have not included them in the
having
general tables. Recorded Results
of Lithotomy in Private Practice.
are not
distinguished.
’
The Statistics of Lithotrity are confined to the results which M. Civiale has published of his own practice. No other surgeon who has
extensive scale has given a complete account of all the cases on which he operated. This omission is greatly to be regretted ; yet the manner in which M. Civiale’s publication was received, both in France and in other countries, was little calculated to encourage other practitioners to follow his example. I well know that the statistics of M. Civiale have been severely criticized, and that he has been openly accused of serious omissions in the several accounts published by him. I must leave the responsibility of their correctness on that distinguished surgeon, having neither time nor inclination to re-open a discussion which has now been closed for so many years, even in France. The followingis a tabular view of M. Civiale’s results :-
performed lithotrity
on an
Proportion,1 Children Adults
In this
...............
306 231 59
Total ............
596
..................
..................
OJd People
’,
in 6-43.
have contributed little or nothing to the statistics of Lithotrity. Sir Philip Crampton, and Mr. Teale, of Leeds, are the only surgeons who have published an account of the whole of the cases which occurred to them. In this particular they merit praise, but no conclusion can be drawn from their limited number of cases ; and I say this with great respect for these excellent surgeons. * Repertorio di Piemonte. August, J839. + Fihatro Sebezio. July, tga9.
country
CRETINISM
we
AND
GOITRE.—A report
on
the number
of persons afflicted with cretinism or goitre, in the department of the Bas-Rhin, has just been published by Dr. Tourdes. In 1852, according to the return of medical men of the different cantons, the disease existed in 38 communes. The number of cretins in these communes was 125 ; and that of persons affected with goitre, and not idiots, 873. The causes of this disease are still to a great extent mysterious ; for there are communes free from it, and yet having the same character as others in which it most prevails. Many medical men have attributed cretinism and goitre to the water of particular localities; but Dr. Tourdes analyzed the water in communes where goitres were very prevalent, and in others where they did not exist, and discovered no difference. It appears, however, that the disease in the BasRhin is much less extensive than it was several years ago ; and the diminution coincides with the draining of the marshes, and the improvements in the cultivation of the soil. ’