Calculi of the bladder are for the human race, and the more so for male individuals, one of the most intolerable diseases that life can be afflicted with. In addition to the pain and the dangers of the condition, and the pain and dangers of treatment, there are also certain moral feelings, predisposing the soul to sadness, which are closely bound to the affliction, and constitute a complication of varying seriousness to this so distressful state.
The work by Mr Civiale on this matter, of which we are to give an account today, concerns the application of the numerical method to a large number of questions concerning calculi.
Mr Civiale has painstakingly collected a body of research presented in a large number of tables derived from diverse populations, in the main cities, and in the largest hospitals in Europe.
The analysis of these tables, conducted by Mr Civiale, provided him, by using numerical information, with the means of confirming or correcting several of the results derived from general studies of pathogenesis, which were already suggested by inference or very precise summaries in clinical observation. We will report several of these findings to the Academy so that it may better appreciate, by its own judgement, the considerable work done by Mr Civiale.
It had been thought until the present day that in certain families parents transmitted an organic disposition to their children, whereby these children were more inclined than others to contract calculi; and from there, the conclusion drawn was that this disease was hereditary.
On this point a fairly large number of facts, it is true, indicate that the children of individuals suffering from calculi have in turn been affected; but the instances in this category are counterbalanced in a powerful manner by even more numerous instances in the opposite category. In the first instances, indeed, can be found the pressing consideration that the disease may have developed in the children under the influence of the same circumstances that had produced it in the first place in their parents or ancestors, therefore outside any hereditary path. Moreover, to cast as much light on this question as is desirable, it would be necessary to compare, on a large scale, the relative proportion of subjects suffering from calculi whose parents also suffered, and the proportional number of subjects in the reverse case; but information is lacking to cast light on this matter.
It has long been known that calculi are far less frequent among women than among men. In addition, among women, the chances of success after an operation are far greater. The numerical results obtained on this point tend to prove that over an equal number of operations, half as many women as men are lost.
The detailed study of the causes likely to produce calculi disprove a certain number of statements issued in relation to different foods and some beverages that were too hastily declared to be likely to cause the disease. Whatever the research taken into consideration, everything remains obscure, there is nothing but uncertainty on this point.
The numerical relationships established as to the main periods in life more particularly afflicted by this disease show that more than half the sufferers are not more than 14 years of age: in Lyon's hospitals, according to Poutéan, seven to eight children are operated on against one adult. This proposition is not however true in all localities. While demonstrations of this effect are most convincing for Wurtemburg, the Lorraine and Barrois hills, the Italian slopes of the Alps, and some English counties, etc, it appears on the contrary that in other localities, and, for instance, in very hot or very cold countries, adults and old people are more exposed to this condition. It can be added that everywhere the children suffering from calculi belong almost exclusively to the poor classes, while adult and elderly sufferers are evenly distributed over different social classes. Children are almost always free from the genitourinary damage that is such a cruel affliction for the other age groups.
If, in the tables we have before our eyes, we look for the way in which different professions in social life behave, either in favouring or in obstructing the development of calculi, no explicit information is obtained, no conclusive result reached. Indeed it is observed that the disease is encountered in more or less equal manner in individuals belonging to all trades; and this is true when the relative proportions of each profession are taken into account. It is probably true that there is a greater proportion of sufferers in the least well off classes; but it is also unfortunately these classes that are the most numerous; and moreover it is also on these classes that the burdens of material existence weigh most, disease in particular.
The conclusions at which Mr Civiale arrived with respect to professions are similar to those relating to the influence of climates. Calculi have been observed in almost equal manner in all countries. Assertions to the contrary are flawed with exaggeration or inaccuracy. It is true that several circumstances, either unnoticed or ill-assessed, may have contributed to the spread of this error. It suffices that for some reason general attention is drawn here or there to a disease for the examples evidenced of this same disease to increase markedly. In the lifetime of the illustrious lithotomist Raw, for instance, it could be thought that calculi were a very common disease in Holland, on the basis of the considerable number of operations performed at the time in Amsterdam hospital. After Raw's death, the number of operations decreased by more than half, and the number today has dropped to around one-third. In the same way the great and useful institutions which have multiplied so much in present times for the benefit of the mentally alienated, as well as the numerous establishments created for the treatment of growth deviations, have brought to light a large number of diseases and illnesses of these sorts which would otherwise have gone unnoticed.
It is however above all, the parallel between methods used to attack and destroy calculi that concerned Mr Civiale, and it is also this crucial part of his work that we will follow with keener attention.
It would be fairly exact to say that the means that have been used successively to control the progress of this cruel disease can be summed up in three general methods. Each of these methods, identical as to their objective, could however involve various series of procedures which we will not enumerate here.
First method
Attempts have been made, but thus far in vain, to dissolve calculi in the bladder by the action of what are claimed to be indirect or direct lithotriptics, general or local.
Second method
Attempts have been made to rid patients of their calculi by incisions and openings, often very varied in their techniques, but always by dieresis or by operation involving cutting instruments.
Third method
The calculi are extracted via the urethra without any incision, and most often accompanied by previous mechanical breaking.
The first method, which aims to dissolve the calculi in the bladder using agents derived from physics, chemistry or medicine, was not broached by Mr Civiale, and we will certainly offer no criticism with respect to this silence. We can however say that at the end of his work Mr Civiale makes a passing disapproving and even disparaging mention of the scientific efforts that have consisted in trying to dissolve the calculi inside the body. We cannot disapprove of this viewpoint, nor make a judgement on it: we would like to keep faith both in the resources of human wit, and in the future of science. Between the thinking of Albucasis, to whom the idea of crushing the calculus within the bladder should very probably be attributed, and this important operation carried out for the first time on a living person and recorded in the annals of science and medical art by Mr Civiale, there is a lapse of time of five or six centuries, during which time there were numerous vain efforts, and no doubt some sarcasm and no less incredulity: none of this prevented the discovery. It will perhaps be so one day for lithotriptics. The academy in the meantime should lead the person who reaches this objective to expect ample reward. It is above all to promote such work that the fruitful generosity of Mr de Montyon was established, and should endure.
It is therefore solely between operation by incision and operations consisting in crushing that Mr Civiale has chosen to establish his comparison.
In the history of this art, the power of figures has already been invoked to assess the relative value of the most prominent procedures used within the scope of the second method, that which always involves an operation by incision. But these comparative calculations, made on not very accurate bases, cannot take the place of science. The 4500 operations attributed to Brother Jacques; the 1547 attributed to Raw, the 316 to Baseillac, the 310 to Lecat, and the 150 to Pouteau, on which the claim that the procedures used by these practitioners were superior was so often based, are for the most part not authenticated, no details or assessments are provided, so that they have no value.
Later other work of similar nature was published. We can mention the publications by Doctors Marcet, Smith, Prout, and Yelloli. But Mr Civiale hastens to recognize that for these facts sufficient detail, desirable accuracy, reasoned critique, and fair assessment are all lacking. And it would be a source of serious error if, on the basis of these tables, we were to claim to determine the numerical proportions of mortality after incision with any degree of accuracy.
In the work which it is our task to present to the Academy, Mr Civiale has succeeded in collecting together a total number of more than 5000 instances, all supplied by the practice of the greatest surgeons alive today in Europe. Here are the general conclusions at which he arrived. Of the 5715 operations by incision that he was able to analyse, he found 1141 deaths, 4478 complete cures, and some 100 infirmities as a result of the operation. Thus, in the only instances where results are well known, mortality is around one-fifth for all ages. It is however noteworthy that more than half the patients had not reached their fourteenth year, and it is known that chances for recovery at that age are doubled at least.
On the other hand, these tables also comprise a total of 257 patients treated by lithotripsy, among whom there were only 6 deaths, and among these there were barely 2 or 3 who were under 14. This gives less than one death for 42 patients treated by lithotripsy.
And to complete the demonstration of the superiority of lithotripsy over lithotomy, it can be added that since the discovery of lithotripsy, among a fairly large number of physicians suffering from calculi, hardly any can be cited as having resorted to lithotomy: all were operated on by lithotripsy.
However, in good logic as in good medicine, it is not on this score that the discussion should dwell today. It is indeed not a question of rejecting lithotomy entirely always to replace it by lithotripsy: nobody disputes the fact that today in a fairly large number of cases lithotripsy is dangerous, difficult, or impossible, and that consequently lithotomy is then preferable or even indispensable. Thus the question is clearly: what are the pathological conditions in which lithotripsy offers more chance of success; what are, conversely, the circumstances in which it will be necessary to resort to cystotomy, in other words, the question is to define the respective indications of lithotripsy and incision. Let us now see what Mr Civiale's tables provide in the way of a solution to this problem.
We hasten to seize this opportunity to broach the question of the application of the calculation of probabilities to medicine. It is above all questions of this nature that physicians should bring to this institution. Here they can be sure of careful judgement by competent judges.
Medicine, where work is characteristically difficult, slow, lacking in splendour and glory, has all too often sought to hitch on to ideas that are fashionable in the opinion of the day. Thus, at present, statistics are constantly applied to most of the major questions in therapeutics. Yet in this case statistics are no more than an attempt at application of calculation of probabilities. Let us try to see what opinion we should form.
In the field of statistics, that is to say in the various attempts at numerical assessment of facts, the first task is to lose sight of the individual seen in isolation, to consider him only as a fraction of the species. He must be stripped of his individuality so as to eliminate anything accidental that this individuality might introduce into the issue in hand.
In applied medicine, on the contrary, the problem is always individual, facts to which a solution must be found only present themselves one by one; it is always the patient's individual personality that is in question, and in the end it is always a single man with all his idiosyncrasies that the physician must treat. For us, the masses are quite irrelevant to the issue.
Calculations of probability, in general, show that, all other things being equal, the truth or the laws that are to be determined are all the better approached if the observations used embrace a large number of facts or individuals at once. These laws, then, by the very manner in which they are derived, no longer have any individual character; therefore it is impossible to apply them to the individual chances of a single man, without exposing oneself to numerous errors.
All the applications that one might wish to make, even within certain limits, to a particular isolated case would be liable to error. Where would one be, if for instance one were to positively assign the sex of an unborn child from the fairly exact established ratio of the proportional number of male and female births? What result could be expected if one were to try to determine the time when Pierre is to die from general mortality tables?
The calculation of previous or known events for the purpose of reaching a certain degree of probability for circumstances belonging to similar future or unknown events can only provide valid inferences if one does not at all know the nature of the future event which is the object of the calculation. This is assuredly never the situation of the physician at a patient's bedside.
Statistics in practice, which are always, in the end, mechanisms applied to the calculation of probabilities, necessarily require infinite masses, unlimited numbers of facts, not only with a view to coming as close as possible to the truth, but also, using known procedures, to eliminate, as far as possible, the numerous sources of error that are so difficult to avoid.
Everything presents itself differently in medicine: the facts are always very limited for us, by the very nature of things; they are even more so by the fact that we are unable to know and assemble them all. Alongside a few hundred facts published by a small number of men who write profusely, there are thousands of other facts lost in the obscurity of the voiceless clinical practice of that multitude of physicians who, in the midst of practical usefulness of every instant, cannot find time to write at all, and who even hardly have the time to read. Thus, in practical medicine, facts are too few to enter into the field of probability calculation. In addition, the great majority of these facts are not available for calculation, comparison or assessment: and yet what elements, what results would all these lost facts introduce into the issue, into this medical arithmetic? None can presume to say.
The mathematicians who have concerned themselves with the calculation of probabilities have all emphasized the need for the greatest accuracy and care in the classification of facts so as to avoid ill-considered and inaccurate associations which so readily lead to error. They all require that only elements of the same nature, and facts that are comparable one to the other, should be entered into a calculation, in other words facts that have undergone previous examination and analysis, so that as far as possible the conditions of the analogy or dissimilarity that they comprise are fixed.
Observations in the field of medicine are far from being able to comply strictly with these conditions. In medicine the danger is at once the errors that arise from the very nature of the question, and the errors that can be introduced by the men trying to answer the question.
In this sort of subject matter, so many variable conditions, so many diverse circumstances, so many contradictory elements are inevitably involved, and also introduce such a large number of accidental, irregular, and disrupting occurrences that it is impossible to enclose them all inside calculable limits. Experience has proved that in given circumstances a considerable number of patients can be operated on without a single one being lost, while in other circumstances almost all who are operated on are lost.
The diversity of medical constitutions, even in reference to specified seasons, introduces notable differences. Indeed sometimes successes are easy, numerous and assured because the operation and its sequels do not encounter difficulties or obstacles; sometimes on the contrary problems are prompt to occur, frequent and almost inevitable, because severe inflammatory problems, grave bilious complications or violent nervous attacks aggravate the situation.
Further again, everything has an influence on the success or otherwise of the operation: the operative procedure itself, not only considered per se, but also in relation to the hand that performs the workbecause of the confidence derived from the habit of practising the operationthe season, the climate, and even the place in which the operation is performed. Successes are not at all the same in a large hospital, which is always more or less crowded, in a small hospital where there are usually less people, and in a private house, all other things being equal.
The duration of the illness before the operation, the various forms of damage to the bladder and related organs caused by the presence of the calculus, the general constitution of the patient, his moral and physical disposition at the time of the illness, the ceaseless activity of the organism under the more or less powerful action of life and its functions, all these are among the important circumstances which, for physician, render the cases so variable and unpredictable, so difficult to compare one with another, so open to numerous sources of error, that no law of probabilities can encompass them all. It should also be noted that among all these circumstances none belongs to the category of those which are so small as to be considered negligible in the calculation.
In fact in medicine, even regular circumstances and causes phenomena are most frequently complicated, obscured, unknown, and their action is upset or reversed by such a large number of accidental factors that they cannot be seized upon by calculations. A calculation could not indeed reach the minute detail of combinations when they are so varied, and when they multiply and involve complication beyond a certain level.
When our famous Morgagni, with all the power of his genius, equally able to collate facts and to deduce from them the most accurate and judicious conclusions, said: Non numerandae sed perpendendae observationes, one should not count, but rather weigh the facts, he energetically expressed one of the most important conditions attached to the theory of calculation of numerical probabilities applied to medicine.
This being said, is it because the inflexibility of the calculation and the apparent strictness of figures cannot be applied in an absolute manner to medicine, that our science does not even so possess a series of probabilities that can be assessed? that it cannot reach a certain degree of assurance in its progress? or that there is no form of certainty to be derived from its results? Certainly not, and in this we have with us the agreement of a certain number of eminent mathematicians; the condition of medical sciences, in this respect, is no worse and no different from that of all physical and natural sciences, of jurisprudence, of moral and political sciences, and so forth.
Whenever it is not possible for the human spirit to rise to the mathematical certainty that can be found in astronomy for instance, the consequent requirements of reason are to draw analogies with what strikes the imagination and commands understanding: the logic of the facts turns to the logic of thought. Reasoning then takes on the form of a sort of calculation the result of which acquires ascendancy over our belief, precisely on account of the effect of repetition of judgements or observations. The validity of this calculation depends here, as elsewhere, on the choice of data, and then on the appropriate use of these data. And this appropriate use can only consist in the most detailed examination of the circumstances attendant on each piece of information, in the care taken to break down the information as far as possible, so that pronouncements are made on propositions of an equal degree of simplicity, and of an equal degree of evidence, and so that one guards against any partiality in favour of any particular result.
It should be added that, on almost all points, the calculation will give hardly more than what inference has already provided, and what reason alone might well have suggested.
It can clearly be seen that the main means of reaching the truth are inference, analogy, hypotheses based on facts and continually verified and corrected by new observations, and a sure sense of touch given by nature and strengthened by numerous comparisons between indications it provides and experience which guides it.
After these reflections, for which we might be tempted to apologise to the Academy, we must hasten to do Mr Civiale justice and render the appropriate tribute, that he has already on several occasions deserved and won here. Today we must say that his new work, as it stands, will have provided new evidence for the advantages that in most circumstances are attached to the substitution of an easy, simple operation presenting few dangers for another serious, alarming and painful one which until now constituted the only resource of medical art.
The commissioners invite Mr Civiale to pursue his statistical research to increase the volume of data, and to provide more circumstantial detail to make it more conclusive; at the same time, they are honoured to call for the approval of the Academy for this work.
Notes
Published in Comtes Rendus de lAcadémie des Sciences, Paris 1835; 1:16777. Translated for the International Journal of Epidemiology by Angela Swaine Verdier.