f V NKMlTlKOAf-^ p/ i’KOro'SAL, ON STATISTICS H- CH’NR/v’TlQKS Acc. No. i 3 i~7 7 The Library, St. Thomas’s Hospital, Medical School, London, S.E.1. Lacks title-page and folding tables. Ref. BISHOP (W.J.) & GOLDIE (S.) BiobibHog. of F.N., 1962. The Library, St. Thomas’s Hospital, Medical School, London, S.E.1. Digitized by the Internet Archive in 2015 https://archive.org/details/b21309188 PROPOSAL FOR $injpto Statistics of Surgical Operations. Some time ago the attention of the medical profession was occupied with an important discussion on the mortality from surgical operations, resulting in certain conclusions as to the causes of this mortality in different hospitals and in different countries. Having been engaged some time previously in endea- vouring to further a more uniform system of hospital sta- tistics generally than had previously existed, I was naturally interested in the discussions alluded to, and a very cursory examination of the statistical data adduced was sufficient to satisfy any one that the real mortality due to operations had not as yet been ascertained with sufficient accuracy to enable a just comparison to be made. The data employed may be described as follows : — So many operations of such and such a nature, without reference to age, sex, or cause of the operation, followed by so many deaths, without reference to age, sex, or complications. Given these elements, divide the one by the other, and you get the mortality. PROPOSAL FOR IMPROVED A statistical proceeding such as this can at best lead to very loose approximations. It can convey but a very im- perfect idea of the real state of the case. And one thing is quite certain, that it can lead to no practical result whatever, either as regards the true causes of the mortality, or how these may be mitigated. The first step in the way of improvement is to obtain a terse and accurate registration of the elements of the problem. Every well-kept hospital record ought to contain these. But for the sake of uniformity, I enumerate them as follows : — i. Age. а. Sex. 3 Occupation. 4. Accident or disease leading to operation. 5. Date of accident and of operation, or date of operation if from disease. б. Nature of operation. 7. Constitution of patient. 8. Complications occurring after operation. 9. Date of recovery or of death. 10. Fatal complication, a. Resulting directly from the accident, b. Occurring after the operation. These elements are of so much importance, that it would be well to enter them in a separate operation-book. Having obtained them, the next step is to tabulate them for use ; and to do this properly two forms are required. 1. Including all the operations, with their results. 2. For registering fatal cases. Copies of these forms are herewith transmitted. Table I. is for tabulating the surgical operations performed. In this table, the ordinary English nomenclature of operations STATISTICS OF SURGICAL OPERATIONS. 3 is adopted (with its numerous Anglicized Latin and Greek words) as the one most generally in use. The great opera- tions are classed under two separate heads — those resulting from injury ; those rendered necessary by disease. By so doing, we are able to eliminate the effect of shock, and also of the state of health of the patient; the former consequent on the accident, the latter as influencing the result of the operation. After several trials, the sexes and the ages have been given for quinquennial periods up to 20 years, thence to 60 by decennial periods, and from 60 onwards again, by quin- quennial periods. This enables the influence of each (sex and age) on the result of operations to be ascertained. For the purposes of abstracting, the disease or injury requiring opera- tion should in every instance be tabulated in a word or two. A column has therefore been provided for this purpose. The most important perhaps of all the elements are the complications occurring after operation. It is these which mainly determine the result of the case, while they at the same time afford the most insight into preventible causes of mortality. As it is a matter of primary importance to adopt a common nomenclature of complications, one has been pre- pared, which is printed on each form for reference. In filling up the column of complications, this nomenclature should be as far as possible adopted. It has been tried on an experience of upwards of 800 operations, in 141 of which there were distinct complications. The first result of the tabulation was to show that 66 of these complications were referable to pyaemia, cellular inflammation, erysipelas, sloughing, suppura- tion, gangrene, diarrhoea, and bedsore, diseases notoriously connected with defective sanitary conditions in wards, or with 4 PROPOSAL FOR IMPROVED constitutions in patients so bad as to render doubtful the pro- priety of operating at all. Table No. II. is intended to tabulate the fatal complica- tions and causes of death. It is constructed to correspond with Table No. I., in order that, by simple arithmetical pro- cesses, the mortality from each operation for each sex and age, and also for each complication, may be readily ascertained. The same nomenclature, both of operations and of complica- tions, is adopted in this as in the other Table ; and two columns are added in which to enter the average duration of the cases (in days) from the date of the operation to that of the death. The causes of death in 483 fatal operations have been compared in this way : and one result has been to discover that 190 deaths (or nearly 40 per cent, of the total mor- tality) were occasioned by pyaemia, phlebitis, cellular inflam- mation, erysipelas, sloughing, suppuration, gangrene, diph- theria, pneumonia, and fevers, typhoid and hectic. No less than 50 deaths occurred from these two last diseases. Another result has been to ascertain the great difference in relative frequency of complications in different hospitals. Thus out of three large hospitals, one returns 25 per cent, of its mortality after operations as being due to the fevers mentioned above ; while the other two hospitals return not a single death from fever. In one of the hospitals, 27 per cent, of the deaths are returned as due to shock ; in another 2^ per cent. ; in another less than 1 per cent, are attributed to this cause. In one hospital 33 per cent, of the deaths are attributed to peritonitis ; in another 3! per cent., and in the third 22 per cent. The deaths from pyasmia are returned from one hos- pital as amounting to j 2 per cent, of the total mortality ; from another at 4 ^ per cent., and from a third at 14 per cent. STATISTICS OF SURGICAL OPERATIONS. 5 Cellular inflammation, erysipelas, sloughing, suppuration, and gangrene, together yield in one hospital a proportion of 2 per cent. ; in another 6 per cent. ; in another 15 per cent, of the total mortality. The comparative frequency of complications, not attended by fatal results, varies in an equal degree. The facts already ascertained, imperfect as they are, point to the following consequences : — First : That the sanitary condition of hospi- tals has a much greater effect on the result of operations than could have been anticipated. Second : That in describ- ing the complications, the same name is not always used to signify the same thing. The data at my disposal are too limited to allow of the comparative effect of age and sex on mortality being discovered ; but, incomplete as they are, they all go to prove the necessity for adopting a uniform nomenclature of complications, and a uniform method of tabulation. The one drawn up will, . in the opinion of the highest authorities, be found suitable for every purpose : it has been tried on a somewhat large scale and has been found to answer. Every annual hospital report should contain a digest of the previous and past years’ statistics, including those of its operations, on a uniform plan. For the general registration of cases, the forms and method, which were submitted by me to the London meeting of the Statistical Congress, and laid before the meeting of the Social Science Association at Dublin, will be found to answer the purpose ; and the forms for regis- tering operations I now submit, which were received with approbation at the last International Statistical Congress at Berlin, complete the work I took in hand. These are actually in use at St. Bartholomew’s Hospital in London, and their results will shortly be printed. 6 PROPOSAL FOR IMPROVED It will not, of course, be necessary to print the entire forms in each annual report. In most hospitals not above a dozen or fifteen lines will be required every year. In the trials I have made, I find that the complications following on 811 operations can all be included in thirty-four lines, and this is a much larger number of operations than is ever likely to be registered in any one year in any hospital. In the smaller class of country hospitals the annual T able would rarely exceed half-a-dozen lines, so that no one need be alarmed at the appa- rent magnitude of the Tables. I am fain to sum up with an urgent appeal for adopting this or some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life — often ignorantly attributed to want of skill in the Physicians and Surgeons ; and that, as a general rule, the poor would recover better in their own miserable dwellings if they had proper medical and surgical aid, and efficient nursing, than they do under more refined treatment in hospitals. But few have had so sad or so large an experience as I have had to lead them to this conviction. It is imperative that this impression should be either dissipated or confirmed. In attempting to arrive at the truth, I have applied every- where for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of compa- rison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to. They would show subscribers how their money was being spent, what amount of good was really being done with it, or whe- ther the money was not doing mischief rather than good : STATISTICS OF SURGICAL OPERATIONS. 7 they would tell us the exact sanitary state of every hospital and of every ward in it, where to seek for causes of insa- lubrity and their nature ; and, if wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of ascertaining at present. They would enable us, besides, to ascertain the influence of the hospital with its numerous diseased inmates, its overcrowded and possibly ill-ventilated wards, its bad site, bad drainage, impure water, and want of cleanliness — or the reverse of all these — upon the general course of opera- tions and diseases passing through its wards ; and the truth thus ascertained would enable us to save life and suffering, and to improve the treatment and management of the sick and maimed poor. Florence Nightingale. London , December y 1863. 1 LONDON I SAVILL AND EDWARDS, PRINTERS, CHANDOS STREET, COVENT GARDEN. , KING’S College LONDON ~7oMHiS (?/\ Urjf V iir- Library HodCk/tl fdoYddAL foil t M ST/9 'Xl ( "(a I Of S\)l (r c C4 L oHm IX 0*j± mi 201096215 2 KING’S COLLEGE LONDON ■ ? The Library, St. Thomas’s Hospital Medical School, London, S.E.1 The L ibrii.j, St. Thomas’s Hospital, Medical School, London, S.E.1.