THE SCIENTIFIC USE OF HOSPITALS

EVERY medical student, both he who has had the pleasure of receiving a prize and he who has not been so fortunate, will doubtless agree with me when I say that much, very much, has to be learnt by him who is striving to join the medical profession. But that which such a one has learnt or is learning consists of things which are known; and before long, I trust, another thought will become uppermost in his mind-the vast extent of the unknown which has to become known, and which has to be learnt in order that the healing art may gain the reach and certitude of sway over disease which we all yearn for it to possess. Such a thought is always present in my own mind; and I trust that I am not doing amiss if I venture to dwell in these pages on another thought arising out of the former, and, like it, much in my mind-the thought, which takes the form of a complaint, that the advance of medical knowledge is not so rapid as it might be, by reason of the fact that in our hospitals adequate use is not made of the great opportunities which these offer for gathering in new medical truths.

Let me first say a word or two in order to disarm beforehand adverse criticism.

There are people, I am aware, who maintain that public charities, such as are our hospitals, ought not in any way to serve for the advancement of medical knowledge; and we hear again and again much misdirected talk against hospitals being used for the purposes of experiment. A certain amount of agitation is, in fact, going on under the influence of this idea. Such an agitation is, I venture to say, a mere kicking against the pricks.' Our hospitals always have been and always must be, from the very nature of things, the great means of advancing medical knowledge.

I ought to have no need to insist, were it not that they who fan the agitation I have just spoken of seem to need its being told, that whenever a sick person appeals to a healer for help, he, by the very act, makes himself the subject of an investigation. I ought to have no need to insist that every touch of the surgeon, every counsel of the physician, is by its very nature more or less an experiment.' For, on the one hand, he, the physician or surgeon, cannot be

absolutely sure of the result of his act; while, on the other hand, he is prepared to make use of the knowledge afforded by the result. And these two things constitute the very essence of a scientific experiment. The fact that the object of the act is not to advance knowledge but to bring relief to the individual patient does not make the act any the less an experiment; nor does it prevent the knowledge gained by the result being made of use to others.

In every case of treatment of the sick there is a factor of uncertainty, and this factor, by which each act of the healer becomes an experiment,' varies widely in different cases. It may be insignificant-it can never be wholly absent-or it may be considerable. How far the healer in any particular case ought to go in the direction of uncertainty must depend on the special circumstances of the case, and must be determined by one consideration alone-the welfare of the patient. Judged by this-by the welfare of the patient-it may in one case become the duty of the healer to plunge into the unknown guided by the slenderest clue; in another case he would be justly blamed if he swerved ever so little from the trodden path.

Thus every hospital, and indeed every consulting-room, is in reality, beyond all denial, the seat day after day of a continued series of experiments, each conducted for the welfare of the patient who is the subject of it. Were such experiments conducted not for the welfare of the patient, but simply for the advancement of knowledge, there would be justification for the attitude of some of whom I have spoken. But I venture confidently to assert that they are not so conducted. Much as the physician or surgeon may desire, and rightly desire, to profit by the knowledge gained through his 'experiment,' his action is in every case directed not to the desired intellectual gain, but wholly to the welfare of the patient. But while he is thus bent on healing the particular sick man who is the subject of the ' experiment,' it is not only permissible for him to make use of the knowledge afforded by the experiment,' it is his duty to do so, for this reason alone, if for none other, that the newly gained knowledge makes for the welfare of succeeding patients. The whole progress of the art of medicine lies in the knowledge gained by one experiment' lessening the factor of uncertainty in succeeding experiments,' and so making the art less and less experimental, more and more sure and effective. The increment of knowledge gained by each experiment' may be written out as a decrement of human suffering and pain.

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The complaint which I am now venturing to make is that the teachings of the multitude of 'experiments' made daily in our hospitals are not adequately laid hold of. Chiefly, and foremost, would I insist on one great shortcoming-namely, that the analysis of the phenomena presented at the bedside and in the post-mortem

room is not so exact, so complete, and especially not so systematic as it might be and as it ought to be. I am fully aware of the great progress which has been made since the days when I was a student. It was while I was a student that the clinical thermometer, that type of exact physical analysis, came into use; before that time every one had to be content with an inexact and delusive test of temperature the feeling of the hot skin. I am fully aware of what other progress has been made in the physical, in the chemical, in the bacteriological, or, as I would rather say, in the biological analysis of disease. But I nevertheless venture to assert that all such analysis, extended and improved though it be, still falls far short of what it should be. If we are to master the secrets of diseases, we cannot too much strive to learn; we cannot make the analysis of each experiment too exact or too complete.

Here in passing let me, with the view of disarming popular criticism, point out that the full and complete analysis of which I am speaking must, like the rest of the 'experiment' of which it is a part, be so conducted that the object of the experiment, the welfare of the patient, is kept clearly in sight. But by the welfare of the patient I mean the real welfare intelligently grasped, not what ignorance may mistakenly conceive as welfare. I well remember how, when in the dark places of a country practice I began to use the clinical thermometer, I was reproached with needlessly' worrying' the patient by bystanders who did not understand the value of exact knowledge. And in other dark places exact analysis will always be looked upon as needless worrying' by the ignorant onlooker. But the wise and good healer will always be alert to mark the line carried beyond which attempts at analysis cease to make for the welfare of the patient, knowing that the exact point at which careful examination passes over into harmful disturbance must depend upon the circumstances of each particular case.

I need not here dwell at length on each of the many and varied particulars of the exact analysis of which I am speaking. It will be sufficient for my present purpose if I say that the analysis which I have in mind is one which demands the use of the exact methods and of the instruments of precision employed in physical, chemical, and biological inquiry. The phenomena of disease, being phenomena of living beings, present themselves, in most if not in all cases, as problems, as mixed problems of physics, chemistry, and biology, to be grappled with by the doctor as they are grappled with by the physicist, the chemist, and the biologist. The analysis, to be adequate, must be carried out by means of adequate appliances. The days when a test-tube, a spirit-lamp, and an imperfect microscope supplied all the equipment needed for such an analysis have long passed away. Such an examination as the present state of science makes imperative can no longer be conducted in a corner behind a

screen. It is to-day absolutely necessary that, for the carrying out of the exact and complete analysis of the phenomena of disease, demanded alike in the interests of the individual patient and for the well-being of mankind, each hospital should be provided with laboratories, clinical laboratories, fully equipped with all the needed appliances of science.

And the complaint which I am now making narrows itself down to this, that, in spite of all which has recently been done, our great hospitals in London are still very deficient in such an equipment. I venture to assert that in this respect our London hospitals in general are both absolutely behindhand and relatively in the rear of hospitals not only in other countries but even in our own provinces.

Whether or no it is desirable that every large hospital in London should have attached to it physical, chemical, and physiological laboratories for the instruction of students in the sciences introductory to medicine, is a question about which opinions may justly differ. I myself am strongly of opinion that instruction in these sciences would be more economically and at the same time more efficiently carried out in some one or two common centres. But there can be no such divergence of opinion as to the need of each hospital having as a part of its constitution clinical laboratories of the kind of which I am speaking. Such laboratories, not indirectly only, but in a most direct manner, make for the welfare of the patient, and in this respect may be clearly differentiated from educational laboratories. So essential are they to the due care of the sick that the sums necessary for their equipment and maintenance must be regarded as a charge on the general funds of a hospital no less pressing than the sums needed to purchase surgical appliances and drugs.

I cannot here, and indeed need not, dwell on the value of the exact and complete analysis of the phenomena of disease which the possession of such laboratories would render possible. I must content myself with pointing out the double character of the use of such an analysis. In the first place it is most useful, often unexpectedly useful, as a mere determination of facts. Recent as has been the institution anywhere of these laboratories, and limited as still is the employment of them, it has already happened, not once only or twice but often, that some fact laid bare by such a complete analysis, some chemical body detected by exact research, some organism run to earth by careful bacteriological culture, some fact which ordinary old-fashioned examination would never have laid hold of, has been the means of leading up to a correct view of the nature of the patient's malady, and so of bringing relief or even of saving life.

In the second place, the analysis has a larger, more far-reaching

use. Single facts may be of value, indeed, as I have just said, of great value; but the highest value of the results of analysis lies in their general use, in their being made to throw light on the nature of disease. This higher use cannot be carried out by the mere recording in a mechanical manner the results of each analysis, by accumulating gigantic heaps of data, to be turned over by some subsequent inquirer. Such a method of analysis-a method, I fear, all too common-is a method which may occasionally bring truths to the light, but one wasteful of time and energy. To be truly productive, the record of the results of analysis must not be a dead mechanical one, it must be vitalised by a spirit of inquiry. It is the very essence of a successful research that he who is searching should know what he is looking for. Clinical analysis, like other analysis, reaches its highest value when the facts are gathered in with a definite end in view.

The first method of analysis, the mere accumulation of data, with the expectation that this or that fact arresting attention may prove fruitful, may be carried out in a mechanical manner by an inferior agent, whose work perhaps will be all the better if in him care and accuracy are assisted by the absence of ideas.

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The second, the higher method, makes far greater demandsdemands which, I venture to insist, cannot be satisfied under the arrangements which at present exist in most at least of our hospitals. At each of our hospitals, the higher use of the analysis rendered possible by clinical laboratories of the kind on which I am dwelling means a whole series of inquiries, some small, some great inquiries, of which it may with confidence be asserted that their successful prosecution would speedily lead to a great advance of medical knowledge and a lessening of the sufferings of mankind. But how can these many inquiries be adequately carried out? possible inquiries are far too many for the powers of even the whole hospital staff, however able, however energetic. Did every surgeon, every physician, every assistant-surgeon and assistant-physician and the like, down to the lowest grade, do his very best, they could, all told, grapple with no more than a fraction of the problems presented to them day after day. The harvest of truth is plentiful, but the labourers are few. This is what I especially have in mind when I say that much, very much, of the opportunity afforded by our great hospitals for the advance of medical knowledge is running to waste.

Here may I venture, with all the hesitation which ought to mark the suggestions of an outsider--and I, alas! have been for many years an outsider to the profession-to make a suggestion? I hear much nowadays of 'post-graduate study.' I am not sure that I quite know what is meant by these words. Sometimes I hear them so used as if they meant the means of enabling a graduate to learn in an ordinary way what he ought to have learnt before he was a graduate,