Commentary

Big Data & Society July–December 2014: 1–6 ! The Author(s) 2014 Big Data in the 1800s in surgical science: DOI: 10.1177/2053951714543701 A social history of early large data set bds.sagepub.com development in urologic surgery in Paris and Glasgow

Dennis J Mazur

Abstract ‘‘Big Data’’ in health and medicine in the 21st century differs from ‘‘Big Data’’ used in health and medicine in the 1700s and 1800s. However, the old data sets share one key component: large numbers. The term ‘‘Big Data’’ is not synonymous with large numbers. Large numbers are a key component of Big Data in health and medicine, both for understanding the full range of how a disease presents in a human for diagnosis, and for understanding if one treatment of a disease is better than another treatment or better than just leaving the patient on his or her own without therapy. In this paper, we examine the first considerations of Big Data in medicine in Paris in the early 1800s when urologic surgeon Jean Civiale collected the first large numbers. Civiale collected the large numbers to defend the efficacy of his urologic instrument, the lithotrite, and the surgical procedure he developed, lithotrity, for the removal of bladder stones compared with earlier, more invasive surgical approaches. We examine how large numbers were adjudicated in social decision-making in the Acade´mie des sciences, Paris, when a dispute arose among French urologic surgeons about the importance of large numbers in surgical science. After Civiale’s successful defense of his instrument and procedure in Paris, we examine how his approach to Big Data (large numbers) impacted data collection by George Buchanan in his use of the procedure at the Royal Hospital Infirmary in Glasgow.

Keywords ‘‘Big Data’’, bladder stones, large numbers, lithotrite, lithotrity, lithotomy, mortality, survival

Introduction many eras prior to the invention of computers to carry out algorithmic processes. Our focus in this paper will be In this paper, we will examine Big Data of the 1800s in on large numbers—as viewed by urologic surgeons and Paris and Glasgow as it was adjudicated in surgical statisticians in the 1800s—as a component of Big Data. science in a dispute among French urological surgeons. Before computing by machine, when one computed This scientific dispute focused on a new urological sur- only by hand or in one’s head, the term of probabilistic gical instrument and procedure whose use had spread and statistical importance was ‘‘large numbers.’’ The across Europe. The data adjudicator and interpreter in recognition for the need for large numbers first came this case was a commission selected by the Acade´ mie about in science, but not in the medical or surgical des sciences, Paris. The term ‘‘Big Data’’ today is typically defined in terms of algorithmic processes carried out by com- Oregon Health and Science University, USA puters. For example, the Oxford Dictionary (2014) defines ‘‘Big Data’’ in the area of computing specifically Corresponding author: Dennis J Mazur, Center for Ethics in Health Care, Mailcode: UHN-86, as ‘‘data sets that are too large and complex to manipu- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., late or interrogate with standard methods or tools.’’ Portland, OR 97239-3098, USA. However, these types of large data sets have existed in Email: [email protected]

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Downloaded from classic.bds.sagepub.com by guest on June 4, 2016 2 Big Data & Society sciences, rather in arguments in astronomy. In 1755, Civiale’s data set Thomas Simpson commented on the need for large numbers in astronomical observations: As a surgeon with a new surgical instrument and a new procedure, Civiale kept track of his urologic cases that It is well known that the method practiced by astron- distinguished his instrument and procedure from his omers, to diminish the errors arising from the imper- predecessors and contemporaries. This approach was fections of instruments, and of the organs of sense, by a necessity in Paris in the early 1800s, as the taking the mean of several observations, has not been Acade´ mie des sciences had a strong role as an adjudi- so generally received, but that some persons of note cator of disputes among physicians and surgeons have publicly maintained, that one single observation, regarding the assessment of newly developed surgical taken with due care, was as much to be relied on, as the instruments and procedures aimed at replacing older mean of a great number. instruments and procedures for the same or similar surgical problem. Simpson (1755) further argued that ‘‘the more obser- In its role as an adjudicator of disputes among phys- vations of experiments there are made, the less will the icians and surgeons, the Acade´ mie des sciences served conclusion be liable to err, provided they admit of an early regulatory function in French society by bring- being repeated under the same circumstances.’’ ing the typical ‘‘physician versus physician’’ and In 1837, Simeon Denis Poisson, also an astronomer ‘‘surgeon versus surgeon’’ disputes before experts com- but foremost a statistician interested in applying prob- missioned by the academy. In the case of the Civiale abilistic models to data outside of astronomy, developed instrument, the lithotrite, and his procedure, lithotrity, his law of large numbers and encouraged surgeons of his Civiale had what were then considered to be large num- day to study large numbers of patients. This was neces- bers at hand to defend his procedure. The Acade´ mie sary in probability and statistics, as Simpson (1755) des sciences selected experts to evaluate Civiale’s pro- notes, ‘‘...to diminish the error arising from the imper- cedure, including those from the field involved in the fections of instruments, and of the organs of sense.’’ We dispute and Poisson, the main statistical expert of are interested in the examination of the first large data the time. sets used in surgery and of how the Acade´ mie des Poisson, although first interested in the develop- sciences used ‘‘Big Data’’ in France in the 1800s. ment, refinement, and application of mathematical Surgeons have a long history of accumulation of models to the prediction of the orbits of the planets, survival versus mortality data in the use of new surgical also recognized that these mathematical models could instruments and procedures for operations. This is par- be used in other realms of government in a variety of ticularly true in the military, as many new instruments ways. Yet, Civiale’s numbers in terms of his own per- and procedures are invented and used for the first time sonal data, supported by data from urologists across in wartime (Vekerdy, 2005), for example, involving bal- Europe, demonstrated that his less invasive procedure, listic trauma to the abdomen (Mahoney et al., 2005) lithotrity, had a much lower relative risk of the patient and temporary vascular shunts in damage control in dying than lithotomy in all its forms, including the wartime vascular injury (Britt et al., 2002). Marian operation, the Allarton operation, and others Jean Civiale (1792–1867), a urologic surgeon in (Gant, 1878). Paris, developed and maintained one of the largest Jacobson’s and Heurteloup’s instruments to break data sets on a particular instrument (the lithotrite) down the stone were replacing Civiale’s method of per- and procedure (lithotrity) during peacetime. Early forating (drilling) of the stone in the bladder. Also, the instruments for the removal of small stones from the operations and the instruments themselves were becom- bladder through the urethra included the urethra-for- ing more simplified and lithotrity was replacing the ear- ceps of Sir Astley Cooper and Sir Benjamin Brodie lier complicated apparatuses. At the time, problem (Hawkins, 1864). Civiale studied under Dupuytren patients were men with prostatic hypertrophy that and won prizes from the Acade´ mie des sciences in would either have retained fragments of the stone in 1827 (6000 Francs) and 1829 (1000 Francs) for his lith- the bladder or have fragments lodged in the prostatic otrity procedure (Haydn, 1841). Lithotrity involved portion of the urethra. ‘‘bruising,’’ ‘‘crushing,’’ or otherwise fragmenting a Parisian urological surgeons disparaged Civiale’s bladder stone for removal through the urethra without instrument and procedure and took their case to the cutting through the bladder wall. The uniqueness of the Acade´ mie des sciences for adjudication and evaluation lithotrity procedure was its less invasive nature in (Crosland, 2002). Writing in 1837, Lee et al. note removing stones from the bladder compared with lith- that lithotrity (with an instrument inserted into the otomy (cutting through the bladder wall) (Herr, 2009; bladder) was replacing lithotomy (the cutting of the Kiefer, 1968). bladder for stone removal in a surgical operation)

Downloaded from classic.bds.sagepub.com by guest on June 4, 2016 Mazur 3 throughout Europe, although at the time, the authors to take the time to put the data together in a data set did not know if the lithotrite and its procedure, lithot- for analysis and interpretation. rity, admitted to such a universal application as its In his 1868 paper, Buchanan also described the advocates pronounced. Civiale’s data set provided the problems in patient selection for lithotrity in terms of data the l’Acade´ mie des Sciences needed to vindicate characteristics of stone (size, difficulty in crushing, and his lithotrite and lithotrity as a less morbid treatment the shape of the resultant fragments to be removed for bladder stones. from the bladder through the urethra with the litho- trite); the characteristics of the patient and his anatomy Urologist discussions of survival (degree of debility, presence of stricture, presence of an enlarged prostate, atony of the bladder, and chronic In 1862, the British Medical Journal published a report cystitis); and the general health and age of the patient. from a hospital gazette showing that Civiale’s data Given the importance of patient characteristics in deter- from 1860 to 1861 focused on both survival/mortality mining patient risk, Buchanan further notes the follow- and quality of life. In terms of survival, the following ing about the relative mortality of the two surgical was noted about Civiale’s cases: procedures (surgery versus lithotrity): ‘‘It is almost impossible to come to anything like an accurate result Taking all his cases in 1860 and 1981 together, [of the chance of the patient’s survival] by taking num- M. Civiale has had 120 calculous patients: 115 males bers only; still, by taking a very extensive survey, an and 5 females. Of these, lithotrity has been performed approximation to truth may be made.’’ In a pamphlet on 88; of whom, 3 have died, 79 have recovered; and in published in 1880, Buchanan notes that mortality with 6 functional disturbances remain—independent, how- the performance of lithotrity in his hands was ‘‘1 death ever, both of the stone and of the operation. in 7½ cases for all ages, and 1 in 16½ in children under Lithotomy has been performed on 17 patients; of 15 years.’’ But Buchanan did not list the total number whom 8 are cured, 2 have fistulae remaining, and of procedures he had personally performed in patients 7 have died. The remaining 15 patients have not been with bladder stones. operated on; 6 have died, and 9 are still alive. Civiale’s procedure and his supporting However, not only were Civiale’s own patients numerical data as reviewed by the included as data points to support his procedure, Acade´mie des sciences but his lithotrity procedure had also gained widespread support from urologists over Europe who were collect- In terms of Civiale’s patient numbers, 5443 patients ing data on their patients. Civiale added these sets to underwent surgery for removal of the bladder his own data in his report to the Academie des stone(s), and 245 patients underwent Civiale’s lithotrity sciences. Belinaye (1837) notes that with lithotomy, procedure. The Acade´ mie des sciences commissioned 1024 of 5443 patients died, and with lithotrity, 5 of 245 Poisson et al. (1835) to evaluate Civiale’s data. patients died. Commentators (Black, 2001; Matthews, 2001; Tro¨ hler, 2001; Vandenbroucke, 2001) note that this Glasgow urologist’s commentary on type of presentation of data by a surgeon to an Civiale’s data set and Buchanan’s august body of experts—Poisson, an expert statistician; data set in Glasgow Dulong, a physician-chemist; Larrey, a great military surgeon who was Napoleon’s surgeon; and Double, a George Buchanan (1868), a surgeon and lecturer on representative of the medical establishment—was a Clinical Surgery at Glasgow Royal Infirmary, gives an unique form of peer review for Civiale’s era. These insight into how data from one country become incor- evaluators noted that these numbers were ‘‘all supplied porated into surgical practice in the 1800s. Buchanan by the practice of the greatest surgeons alive.’’ notes that the lithotrity procedure was not used exten- Physicians in Civiale’s era considered the set of 5443þ sively in Glasgow for the following reasons: cost of the patient cases a large number. Even though the reported instrument; and once a lithotrite had been donated, the numbers were large, derived from experts across surgeon’s lack of experience and a lack of understand- Europe, and considered even today as ‘‘hard data’’ ing of which patients would most benefit from lithotrity (survival and mortality data (Boivin, 2014)), the over lithotomy. Buchanan then notes that once an Acade´ mie des sciences subjected Civiale’s data to rigor- expert surgeon demonstrated the use of the lithotrite ous review. and the procedure, its use increased. For Buchanan, Poisson et al. (1835) noted that these comparative the additional reason why data are not accumulated calculations were not made on very accurate bases in large data sets is that no qualified person was willing (retrospective review of reported cases); therefore,

Downloaded from classic.bds.sagepub.com by guest on June 4, 2016 4 Big Data & Society they could not take the place of science. In addition, the its reduced invasiveness over lithotomy as recognizable expert reports lacked details of how the expert urolo- without the need for a statistic. Buchanan, a professor gists carried out the assessments. Thus, for the of surgery, was interested in clarifying how deaths Acade´ mie des sciences, these reports fell short of the could be misattributed in such large data sets. goal of determining the numerical proportions of mor- Urologic surgeons showed strong understanding of tality after incision with any degree of accuracy. Yet, how numbers could be used in comparing surgical pro- the commission commended Civiale for recognizing cedures on key parameters like age and death, both the importance of large numbers and many of well ahead of physicians comparing treatments in the the problems interpreting large numbers, especially medical domain. when those large numbers involved a compilation of The impetus for consideration of large numbers in data sets from different urologic surgeons. The health and medical decision-making in the 1800s rested Acade´ mie des sciences concluded that Civiale’s work on surgeons’ collections of survival and mortality data comparing surgical approaches (surgery versus lithot- on the new instruments they developed and the new rity) was moving in the right direction. In the commis- procedures they invented. Internal medicine physicians sion’s report on Civiale’s data, Civiale was encouraged and psychiatrists lagged behind in this era of large num- ‘‘to pursue his statistical research to increase the bers but caught up, as France’s adoption of hospital- volume of data, and to provide more circumstantial based care allowed not only postmortem examination detail to make it more conclusive...’’ but also the in-hospital recording of patients’ histories, symptoms, signs, and physical examination findings Different views on importance of before they died and went to postmortem examination. Civiale’s data: Surgeon versus historian Robert Koch did not discover the tuberculosis bacil- versus statistician lus until the end of the 1800s, and it was a while before physicians recognized this bacillus as one cause of many As noted by Buchanan, surgeons of Civiale’s day were cases of phthisis that had ravaged Europe and the rest already interested in both mortality data and other of the world through preceding generations. In health data, such as the demographics of the patient that and medicine, for physicians other than surgeons, the made a procedure like lithotrity more or less suitable importance of large numbers only started to be appre- to be undertaken. From a historian’s perspective, ciated in the 1800s, even though mathematicians saw Tro¨ hler (2001) argues that Civiale’s report on his litho- their need in society much earlier. But even the statis- trite and lithotrity procedure presented to the ticians of the day, like Poisson, saw the application of Acade´ mie des sciences in 1835 was part of a formal statistics, not so much in health and medicine, but more evaluation of Civiale’s numbers. This evaluation by so in prediction in the courts and the law. Thus, the urologic surgeons and Poisson, as a participant evalu- appreciation of large numbers in internal medicine and ator, needs to be viewed in ‘‘the context of a contest in psychiatry would be further delayed. Physicians need contemporary French medical literature about the large numbers as a key component of Big Data for applicability of ‘statistics’ to ‘medicine’’’ (Tro¨ hler, two purposes: to understand the full range of the 2001). However, Civiale’s numbers on the relative mor- ways a disease may present in a human and to compare tality of his lithotrity procedure versus lithotomy (cyst- one treatment of a disease against another treatment in otomy) were so good from a mortality reduction patients. standpoint that expert urologists throughout Europe Today, the term ‘‘lithotripsy’’ (synonymous with adopted the lithotrity procedure in their own practice lithotrity in Civiale’s day) dominates the urologic and continued with the procedure based on their own research literature and urologists are crushing concre- clinical experience with both lithotomy and lithotrity. ments in the urinary tract through lithotripsy (rather Civiale’s data set on bladder stone removal was the than surgery). Instead of a lithotrite, urologists study- most extensive of its day, and his less invasive proced- ing various crushing procedures for stones in the urin- ure of lithotrity and his instrument (which other urolo- ary system are comparing instruments like the holmium gists in France and around Europe used quickly and laser versus the ultrasound probe. For example, improved upon readily) continued to develop over time. Jako´ bczyk et al. (2011) reported data on 164 patients Even Civiale started using Heurteloup’s instruments in who underwent endoscopic lithotripsy. Of these, 98 his lithotrity practice. were treated with a holmium laser and 66 with an ultra- sound probe. Before surgery, all patients underwent Summary and conclusions urological ultrasound and radiological imaging to localize the stone, and the effectiveness was measured Civiale had the large numbers necessary for statistical using radiological and renal ultrasound imaging. An analysis, yet the success of his lithotrity procedure was effective state was reached if the stone was invisible

Downloaded from classic.bds.sagepub.com by guest on June 4, 2016 Mazur 5 by radiograph and ultrasound imaging after the Boivin J (2014) Formula for successful cost control includes procedure. hard data plus surgeon champion. OR Manager 30(4): Laser lithotripsy was 100% effective in the bladder 14–15, 17–18. (25 of 25 patients), and 89% effective in stones localized Britt LD, Peitzman A, Barie P, et al. (2002) Acute Care in the ureters. Using an ultrasound probe, the proced- Surgery. Philadelphia: Wohlers Kluwer/Lippincott Williams & Wilcott, p. 60. ure was 79% effective (52 out of 66 procedures). With Brown RD, De S, Sarkissian C, et al. (2014) Best practices in laser lithotripsy, two of the patients were found to have shock wave lithotripsy: A comparison of regional practice inflammatory changes of the ureter which necessitated patterns. Urology 83(5): 1060–1064. undergoing open surgery. A third patient sustained a Buchanan G (1868) Reasons for Preferring Lithotrity to perforation of the ureter with laser lithotripsy. The Lithotomy in Operating for Stone in Adult Male, with authors concluded the following: ‘‘The results prove Cases. Edinburgh: Oliver and Boyd; also see Edinburgh that laser lithotripsy is a method of high effectiveness Medical Journal, July 1968;14:6–22. with a low risk of complication. It might surpass sono- Buchanan G (1880) Lithotrity and Statistics of Lithotomy. trode and become its alternative. Both methods have Glasgow: James Maclehose. both advantages and disadvantages.’’ Crosland M (2002) Science Under Control: The French Today, regional studies are being conducted to iden- Academy of Sciences (1795–1914). New York, NY: Cambridge University Press. tify and explain inconsistencies to formulate best prac- Gant F (1878) Science and Practice of Surgery, 2nd ed. Vol. 2. tice patterns for use in clinical urology across regions of Philadelphia, PA: Lindsay & Blackston, pp. 698–700. a country or across countries. Brown et al. (2014) con- Hawkins C (1864) Lithotrity. London: Spottiswood. ducted one such study in the United States to evaluate Haydn J (1841) Haydn’s Dictionary of Dates and Universal such regional differences in shockwave lithotripsy. The Information Relating to All Ages. London: E. Moxon. researchers examined a prospectively maintained data- Herr HW (2009) Civiale, stones and statistics: The dawn of base retrospectively and evaluated regional differences evidence-based medicine. BJU International 104(3): across four distinct American geographic regions invol- 300–302. ving 2240 procedures. The authors found regional dif- Jako´ bczyk B, Wrona M, Lipin´ ski M, et al. (2011) ferences in all parameters. In their conclusions, the Comparison of the effectiveness of crushing concrements researchers state: ‘‘Inconsistencies in regional adapta- in the urinary tract with the use of holmium laser and sonotrode. Central European Journal of Urology 64(1): tion of best practices may identify opportunities for 26–29. further education.’’ Kiefer JH (1968) Jean Civiale (1792–1867). Investigative The most notable differences in the reporting of pro- Urology 6(1): 114–117. cedures of the urologic sciences today compared with Lee E, Johnstone J, Bouillaud J, et al. (1837) Observations on the urologic sciences of the 1800s are the safety of the Principal Medical Institutions and Practice of France, patients and study participants and the care with Italy, and Germany: With Notices of the Universities, and which data is analyzed statistically. Two factors medi- Cases from Hospital Practice. Philadelphia, PA: Haswell, ate the need for large numbers in research studies in Barrington, and Haswell, p. 26. urology today: the primary factor is the need to protect Mahoney PF, Ryan J, Brooks AJ, et al. (2005) Ballistic study participants by not exposing them to unnecessary Trauma: A Practical Guide. London: Springer-Verlag, risks (Mazur, 2007), and the second factor is the need to p. 503. Matthews JR (2001) Commentary: The Paris Academy of study a large enough group of patients to yield statis- Science report on Jean Civiale’s statistical research and tically significant results. the 19th century background to evidence-based medicine. International Journal of Epidemiology 30(6): 1249–1250. Mazur DJ (2007) Evaluating the Science and Ethics of Declaration of conflicting interest Research on Humans: A Guide for IRB Members. The author declares that there is no conflict of interest. Baltimore, MD: Johns Hopkins University Press. No author(s) (1862). Progress of medical science. British Medical Journal 1862; 1: 439. Taken from Gazette de Funding Hopitaux, 25 Fevrier. This research received no specific grant from any funding Oxford Dictionary (2014) Definition of term ‘‘Big Data.’’ agency in the public, commercial, or not-for-profit sectors. Available at: www.oxforddictionaries.com/us/definition/ american_english/big-data (accessed 2 April 2014). Poisson SD (1837) Probabilite´ des Jugements en Matie`re References Criminelle et en Matie`re Civile, Pre´ce´de´es des Re`gles Belinaye HG (1837) Compendium of Lithotripsy. London: JB Gge´ne´rales du Calcul des Probabilitie´s. Paris, France: Bailliere, p. 179. Bachelier. Black N (2001) Commentary: That was then, this is now. Poisson SD, Dulong PL, Larrey DJ, et al. (1835, 2001) International Journal of Epidemiology 30(6): 1251. Statistical research on conditions caused by calculi by

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Doctor Civiale. International Journal of Epidemiology caused by calculi at the Paris Academy of Sciences in 1835. 30(6): 1246–1249; at p. 1247. Published in Comtes International Journal of Epidemiology 30(6): 1252–1253. Rendus de l’Acade´mie des Sciences, Paris 1835; 1: 167– Vandenbroucke JP (2001) Commentary: Treatment of blad- 177. Translated for the International Journal of der stones and probabilistic reasoning in medicine: An Epidemiology by Angela Swaine Verdier. 1835 account and its lessons for the present. Simpson T (1755) A letter to the Right Honorable George International Journal of Epidemiology 30(6): 1253–1258. Earl Macclesfield, President of the Royal Society, on the Vekerdy L (2005) Paracelsus’s great wound surgery. advantage of taking the mean of a number of observa- In: Furdell EL (ed.) Textual Healing: Essays on Medieval tions, in practical astronomy. Philosophical Transactions and Early Modern Medicine. Liden, The Netherlands: of the Royal Society of London 49: 82–93. Brill, pp. 80–81. Tro¨ hler U (2001) Commentary: ‘‘Medical art’’ versus ‘‘med- ical science’’: J. Civiale’s statistical research on conditions

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