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The Uses of Medical Statistics.
106 Course of procedure, founded upon an equally definite i can be to their fellow practitioners is truly great ; with the recognition of the true character of the departure from present great developments of post-graduate work they may health. In some cases this character may be altogether well become more numerous as the opportunities of renewing obscure ; in others it may appear to admit of one out of two familiarity with the latest hospital experience grow more or more solutions ; and in all the first-aid asked for from numerous and effective.
the consultant is accuracy and completeness of diagnosis, in other words, not only the truth, but the whole truth, as far as it is ascertainable. The power of meeting this demand in a satisfactory manner is generally gained in one way-by the most minute possible study of symptoms (whether prominent or obscure) in the wards of a hospital, and by the most accurate possible comparison of these symptoms with the conditions which are disclosed either in the progress of the case towards recovery or ultimately in the post-mortem room. Such a comparison will usually be the more fruitful the less it is associated with hypothesis ; the collection of observations should be large before any attempt is made to use them as a foundation for general deductions, lest these, being premature or erroneous, become distorting media for subsequent experience. No two cases of illness are alike, and the differential phenomena are those which it is of the greatest importance to observe and to remember. The consultant will constantly be called upon to deal with some apparently obvious malady pl1lS x, and his power of determining the value of x will be the element on which his success will in all probability depend. But although assistance in the recondite may be what is generally suught from the consultant, the general practitioner and his patient may stand in need of reassurance where there seems no reasonable doubt of the diagnosis that has been made. It is often particularly difficult to follow the recommendation that the same course should be pursued that has been tried already, and that patience should be maintained in the face of the seeming failure of that course In this situation no one will to remove the conditions. than that rather be found more useful exceptional consultant who is or who has the developing person, from the into the counsellor developed general practitioner of general practitioners. It is true that throughout the busiest years of a successful career such a consultant may be in no close way in touch with the pathological side of hospital work. He must rely for his appreciation of the merits of many new therapeutic developments upon a much smaller personal experience than he who is in honorary charge of many beds in a great public institution; and his chances of having seen more than an isolated case of rare disease will not be so great. So far he must be at a disadvantage in comparison with the more usual type of consultant surgeon or physician ; but, on the other hand, his great experience of the domestic treatment of disease may enable him more readily than one whose professional life is largely confined to the wards of his hospital and the walls of his consulting room to estimate how far in an uncertain case a certain treatment should still be persevered in ; how or,
practitioner is right in estimating the general patient to be no better or no worse over a of illness ; and, lastly, how far details of nursing
far his brother
condition of the
long
term
and treatment could be made less irksome. There is every room for such consultants, and the practical help which they
The main thoroughfares of diagnosis have been marked out by the footsteps of many generations of practitioners ; and it is chiefly in the by-ways that opportunity can now be found for the display of exceptional acumen, or for the exercise of powers of observation trained to notice and to interpret the smallest departures from the customary course of things. There can, nevertheless, be no more fatal error than to allow the obvious to divert attention from the possibly obscure, or to lead to neglect of methods of observation not immediately suggested by the symptoms. The consultant can neglect nothing, and his most remarkable successes will often be the results of leaving no element of the case unexplored. This is the answer to all questions about the born capacity of the student to become a consultant, and as to the part played by luck in the attainment of success in such a position. The special characteristics of successful consultants are observation to see and judgment to weigh, and neither can be acquired save by industry. The most able student may start with the best chance of developing what may be termed the detective faculty, but unless his ability is reinforced by painstaking, minute, and laborious work in the wards his flair will avail him little. The general practitioner who has arrived at the position of a consultant owing to the gratifying fact that he becomes recognised, first in his own locality, and later through a more extensive range of country, as a man who is worth consulting, would never have arrived at that position had he not made extraordinarily good use of his opportunities when attached to a hospital, and could not maintain that position if he did not take all possible steps to keep himself abreast of both scientific and technical A consultant is not a man who is ready to be progress. consulted so much as a man whom his colleagues want to consult, a fact which sometimes escapes the attention of the laity.
The Uses of Medical Statistics. applied to medical the following words of Mr. ARTHUR BowLEY, the author of one of the best modern treatises on elementary statistics. Speaking of THE
limitations
problems
are
the want of
well
of
statistics indicated in
as
recognition by statisticians themselves of the limitations of their work, he says: "At best they can measure only the numerical aspect of a phenomenon ; while very often they must be content with measuring, not the facts they wish, but some allied quantity. We wish to know, for instance, the extent of poverty, its increase or diminution : poverty we cannot define or measure, and we cannot even count the number of the poor ; all we can do is to state the number of officially recognised paupers, and add perhaps some estimates from private sources ; but this gives us no clue to the intensity of poverty in individual cases. Or we wish to obtain statistics of health : all we can measure is the death-rate, and average length of life-very different
107 The statistician’s contribution to a sociological problem is only one of objective measurement, and this is frequently among the less important of the data ; it is as necessary, however, to its solution as accurate measurements are for the construction of a building." Now this is quite
State medicine as well as on the progress of sanitary science in this country. We have already noticedthe general tendency of the new arrangements adopted at Somerset House for the compilation of statistics, as set forth in the Registrar-General’s report for 1909, bat we feel it
true but the time has
desirable again to allude to the matter for the information of those who are not familiar with the official document. Successive Registrars-General have deplored the discrep-
matters.
assuredly passed when it is necessary to justify the skilful employment of statistical methods for the elucidation of medical problems. Certain it is that without such help medicine, as a science, could never have achieved
even
its
present degree
Our first text-books in the
of
study
precision. preventive
of
medicine
are
of the
ancies
existing between the statistical data prepared by the local administrative authorities and those published by the Central Office. This anomaly is due to the fact that whereas, on the one hand, the local administrative
Registrar-General, with which the publications honoured name of WILLIAM FARR, the founder of vital authorities require statistics relating to urban or rural statistics, must ever be identified. The value of the aid re- sanitary districts, on the other hand the tables pubceived from this source has been appreciated by all interested lished annually by the General Register Office relate in the health and prosperity of our people, even where theI not to administrative but to registration districts. But, nature of aid has been most that qualified clearly perceived. unfortunately, the two types of districts are coextensive Hitherto the difficulties Half a century ago RuMSEY of Cheltenham emphasised the in very exceptional cases only. contention that as no public account is taken of the number of general coordination of areas have proved insuperand duration of the attacks of illness which shorten the able, although something has already been achieved in this effective life-time of the people, their condition in respect direction at the request of certain of the larger municipalities. of health and vitality must be inferred solely from the It is satisfactory to learn that such of the difficulties as number of lives lost; and there are facts in abund- were removeable without alteration of statute law have now that the mere number of deaths in been surmounted, and, in view of the almost prohibitory ance to prove any locality bears no constant, or even approximate, character of those difficulties, the credit due to Mr. BERNARD the
ratio
ing
to
there.
the
of
amount
Both the
unhealthiness
personal
actually
antecedents of the
that account proportionately increased. from the year 1911 onwards the returns of Accordingly, natality and of mortality will be arranged and published
existdead
of death now generally escape while the deaths of those who enter a district notice, to die there belong rightfully to another district. Vast numbers succumb in our large hospitals, workhouses,
and the remote
and
asylums
causes
whose
diseases
were
they died, and who there. Accordingly, the
not
the places where
can
have lived
mere
contracted
scarcely
deductions
from
according
to administrative areas,
on
although the facts
must
registration areas as heretofore. The substitution of the former for the latter of these areas renders desirable a still further correction of the returns. In order to ascertain even approximately the death-rate of a given place the deaths of strangers occurring therein must be excluded,
in
be said to
death-rate without
death-rate
is
still be collected for
the life-rate of the inhabitants, may, and often does, lead to fallacious conclusions as to local unhealthiness. Moreover, when the ages of a population are examined, the crudei
and
MALLET
the deaths of natives of the elsewhere
reasonably
place
of
that have been
course, included. being, be contended that in order to
registered
It may, indeed, secure for medical
statistics a reliable and permanent foundation the estabgeneral hasty not infrequently reversed. We doubt whether public: lishment of a national system of sickness registration is would at opinion present support a proposal for the: essential. As a first step the returns of sickness now required of State registration sickness of all kinds throughoutb by the Local Government Board’s orders from the hospital the country. It would appear, however, that with medicalland Poor-law authorities may provisionally be tabulated officers everywhere responsible for the public health, withiand circulated, after expert analysis and criticism by the the army of parochial medical officers in attendance oni statisticians now dealing with the statutory records of birth a
are:
I
the sick poor, and with the Central Department ini and death. Whitehall at their head, the setting on foot of such a
project ought not to be impracticable ; and it should follow that, given the cooperation of the registration staff at Somerset House, the cost of the supplemental service should not be prohibitive. Read in the light of codified information as to sickness incidence the figures relating to deathrates would assume a new importance ; moreover, such a scheme of sickness registration might be highly valuable to public health authorities. The opening years of the current decennium will be remarkable in the history of English vital statistics, as the period in which far-reaching changes have been inaugurated in the arrangement and publication of our national records of mortality and its causes-changes which must necessarily exert a profound effect on the future of
1
See THE LANCET, March 25th, 1911, p. 827.
FOREIGN
UNIVERSITY
INTELLIGENCE.-
AmsterdanaDr. K. Herman Bouman has been recognised as pT’tvat.doeent of Diagnosis of Mental Diseases.-Be’1’lin: The title of Professor has been granted to Dr. Julius Wohlgemuth, Oberarzt of the Frederick the Great Orphanage for Berlin at Rummelsburg; Dr. Erich Muller, surgeon to the Berlin and Brandenburg Cripples’ Home ; Dr. Konrad Biesalski, a laryngologist and otologist; Dr. Josef Herzfeld ; Dr. Max Josph, an eminent dermatologist ; and Dr. Ferdinand Hein, assistant in the University Anatomical Institute. - bornThe title of Professor has been granted to Dr. Karl Grnbe, well known for his researches on diabetes; Dr. Arthur Hiibner, Oberarzt of the University Clinic for Nervous and Mental Diseases.
the consultant is accuracy and completeness of diagnosis, in other words, not only the truth, but the whole truth, as far as it is ascertainable. The power of meeting this demand in a satisfactory manner is generally gained in one way-by the most minute possible study of symptoms (whether prominent or obscure) in the wards of a hospital, and by the most accurate possible comparison of these symptoms with the conditions which are disclosed either in the progress of the case towards recovery or ultimately in the post-mortem room. Such a comparison will usually be the more fruitful the less it is associated with hypothesis ; the collection of observations should be large before any attempt is made to use them as a foundation for general deductions, lest these, being premature or erroneous, become distorting media for subsequent experience. No two cases of illness are alike, and the differential phenomena are those which it is of the greatest importance to observe and to remember. The consultant will constantly be called upon to deal with some apparently obvious malady pl1lS x, and his power of determining the value of x will be the element on which his success will in all probability depend. But although assistance in the recondite may be what is generally suught from the consultant, the general practitioner and his patient may stand in need of reassurance where there seems no reasonable doubt of the diagnosis that has been made. It is often particularly difficult to follow the recommendation that the same course should be pursued that has been tried already, and that patience should be maintained in the face of the seeming failure of that course In this situation no one will to remove the conditions. than that rather be found more useful exceptional consultant who is or who has the developing person, from the into the counsellor developed general practitioner of general practitioners. It is true that throughout the busiest years of a successful career such a consultant may be in no close way in touch with the pathological side of hospital work. He must rely for his appreciation of the merits of many new therapeutic developments upon a much smaller personal experience than he who is in honorary charge of many beds in a great public institution; and his chances of having seen more than an isolated case of rare disease will not be so great. So far he must be at a disadvantage in comparison with the more usual type of consultant surgeon or physician ; but, on the other hand, his great experience of the domestic treatment of disease may enable him more readily than one whose professional life is largely confined to the wards of his hospital and the walls of his consulting room to estimate how far in an uncertain case a certain treatment should still be persevered in ; how or,
practitioner is right in estimating the general patient to be no better or no worse over a of illness ; and, lastly, how far details of nursing
far his brother
condition of the
long
term
and treatment could be made less irksome. There is every room for such consultants, and the practical help which they
The main thoroughfares of diagnosis have been marked out by the footsteps of many generations of practitioners ; and it is chiefly in the by-ways that opportunity can now be found for the display of exceptional acumen, or for the exercise of powers of observation trained to notice and to interpret the smallest departures from the customary course of things. There can, nevertheless, be no more fatal error than to allow the obvious to divert attention from the possibly obscure, or to lead to neglect of methods of observation not immediately suggested by the symptoms. The consultant can neglect nothing, and his most remarkable successes will often be the results of leaving no element of the case unexplored. This is the answer to all questions about the born capacity of the student to become a consultant, and as to the part played by luck in the attainment of success in such a position. The special characteristics of successful consultants are observation to see and judgment to weigh, and neither can be acquired save by industry. The most able student may start with the best chance of developing what may be termed the detective faculty, but unless his ability is reinforced by painstaking, minute, and laborious work in the wards his flair will avail him little. The general practitioner who has arrived at the position of a consultant owing to the gratifying fact that he becomes recognised, first in his own locality, and later through a more extensive range of country, as a man who is worth consulting, would never have arrived at that position had he not made extraordinarily good use of his opportunities when attached to a hospital, and could not maintain that position if he did not take all possible steps to keep himself abreast of both scientific and technical A consultant is not a man who is ready to be progress. consulted so much as a man whom his colleagues want to consult, a fact which sometimes escapes the attention of the laity.
The Uses of Medical Statistics. applied to medical the following words of Mr. ARTHUR BowLEY, the author of one of the best modern treatises on elementary statistics. Speaking of THE
limitations
problems
are
the want of
well
of
statistics indicated in
as
recognition by statisticians themselves of the limitations of their work, he says: "At best they can measure only the numerical aspect of a phenomenon ; while very often they must be content with measuring, not the facts they wish, but some allied quantity. We wish to know, for instance, the extent of poverty, its increase or diminution : poverty we cannot define or measure, and we cannot even count the number of the poor ; all we can do is to state the number of officially recognised paupers, and add perhaps some estimates from private sources ; but this gives us no clue to the intensity of poverty in individual cases. Or we wish to obtain statistics of health : all we can measure is the death-rate, and average length of life-very different
107 The statistician’s contribution to a sociological problem is only one of objective measurement, and this is frequently among the less important of the data ; it is as necessary, however, to its solution as accurate measurements are for the construction of a building." Now this is quite
State medicine as well as on the progress of sanitary science in this country. We have already noticedthe general tendency of the new arrangements adopted at Somerset House for the compilation of statistics, as set forth in the Registrar-General’s report for 1909, bat we feel it
true but the time has
desirable again to allude to the matter for the information of those who are not familiar with the official document. Successive Registrars-General have deplored the discrep-
matters.
assuredly passed when it is necessary to justify the skilful employment of statistical methods for the elucidation of medical problems. Certain it is that without such help medicine, as a science, could never have achieved
even
its
present degree
Our first text-books in the
of
study
precision. preventive
of
medicine
are
of the
ancies
existing between the statistical data prepared by the local administrative authorities and those published by the Central Office. This anomaly is due to the fact that whereas, on the one hand, the local administrative
Registrar-General, with which the publications honoured name of WILLIAM FARR, the founder of vital authorities require statistics relating to urban or rural statistics, must ever be identified. The value of the aid re- sanitary districts, on the other hand the tables pubceived from this source has been appreciated by all interested lished annually by the General Register Office relate in the health and prosperity of our people, even where theI not to administrative but to registration districts. But, nature of aid has been most that qualified clearly perceived. unfortunately, the two types of districts are coextensive Hitherto the difficulties Half a century ago RuMSEY of Cheltenham emphasised the in very exceptional cases only. contention that as no public account is taken of the number of general coordination of areas have proved insuperand duration of the attacks of illness which shorten the able, although something has already been achieved in this effective life-time of the people, their condition in respect direction at the request of certain of the larger municipalities. of health and vitality must be inferred solely from the It is satisfactory to learn that such of the difficulties as number of lives lost; and there are facts in abund- were removeable without alteration of statute law have now that the mere number of deaths in been surmounted, and, in view of the almost prohibitory ance to prove any locality bears no constant, or even approximate, character of those difficulties, the credit due to Mr. BERNARD the
ratio
ing
to
there.
the
of
amount
Both the
unhealthiness
personal
actually
antecedents of the
that account proportionately increased. from the year 1911 onwards the returns of Accordingly, natality and of mortality will be arranged and published
existdead
of death now generally escape while the deaths of those who enter a district notice, to die there belong rightfully to another district. Vast numbers succumb in our large hospitals, workhouses,
and the remote
and
asylums
causes
whose
diseases
were
they died, and who there. Accordingly, the
not
the places where
can
have lived
mere
contracted
scarcely
deductions
from
according
to administrative areas,
on
although the facts
must
registration areas as heretofore. The substitution of the former for the latter of these areas renders desirable a still further correction of the returns. In order to ascertain even approximately the death-rate of a given place the deaths of strangers occurring therein must be excluded,
in
be said to
death-rate without
death-rate
is
still be collected for
the life-rate of the inhabitants, may, and often does, lead to fallacious conclusions as to local unhealthiness. Moreover, when the ages of a population are examined, the crudei
and
MALLET
the deaths of natives of the elsewhere
reasonably
place
of
that have been
course, included. being, be contended that in order to
registered
It may, indeed, secure for medical
statistics a reliable and permanent foundation the estabgeneral hasty not infrequently reversed. We doubt whether public: lishment of a national system of sickness registration is would at opinion present support a proposal for the: essential. As a first step the returns of sickness now required of State registration sickness of all kinds throughoutb by the Local Government Board’s orders from the hospital the country. It would appear, however, that with medicalland Poor-law authorities may provisionally be tabulated officers everywhere responsible for the public health, withiand circulated, after expert analysis and criticism by the the army of parochial medical officers in attendance oni statisticians now dealing with the statutory records of birth a
are:
I
the sick poor, and with the Central Department ini and death. Whitehall at their head, the setting on foot of such a
project ought not to be impracticable ; and it should follow that, given the cooperation of the registration staff at Somerset House, the cost of the supplemental service should not be prohibitive. Read in the light of codified information as to sickness incidence the figures relating to deathrates would assume a new importance ; moreover, such a scheme of sickness registration might be highly valuable to public health authorities. The opening years of the current decennium will be remarkable in the history of English vital statistics, as the period in which far-reaching changes have been inaugurated in the arrangement and publication of our national records of mortality and its causes-changes which must necessarily exert a profound effect on the future of
1
See THE LANCET, March 25th, 1911, p. 827.
FOREIGN
UNIVERSITY
INTELLIGENCE.-
AmsterdanaDr. K. Herman Bouman has been recognised as pT’tvat.doeent of Diagnosis of Mental Diseases.-Be’1’lin: The title of Professor has been granted to Dr. Julius Wohlgemuth, Oberarzt of the Frederick the Great Orphanage for Berlin at Rummelsburg; Dr. Erich Muller, surgeon to the Berlin and Brandenburg Cripples’ Home ; Dr. Konrad Biesalski, a laryngologist and otologist; Dr. Josef Herzfeld ; Dr. Max Josph, an eminent dermatologist ; and Dr. Ferdinand Hein, assistant in the University Anatomical Institute. - bornThe title of Professor has been granted to Dr. Karl Grnbe, well known for his researches on diabetes; Dr. Arthur Hiibner, Oberarzt of the University Clinic for Nervous and Mental Diseases.