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A Broad Conception of Medical Research.
A BROAD
THE LANCET. LONDON: SATURDAY, NOVEMBER 27, 1920.
A Broad
Conception
1103
CONCEPTION OF MEDICAL RESEARCH.
of Medical
Research. As the first recipient of the Royal Society of Medicine’s gold medal, generously endowed by a Fellow who prefers to remain anonymous, Sir A. E. WRIGHT appropriately gave an address on Medical Research on Armistice day. This subject has, of course, been, much discussed in connexion with medical reconstruction, notably by Sir JAMES MACKENZIE, who referred again to it in an inaugural lecture on Oct. 19th at Glasgow,’ and by Sir GEORGE NEWMAN in his well-known reports. These three authorities may fairly be taken as spokesmen of the laboratory, the clinical, and the educational points of view. While as an onlooker the last named is in a better position to survey the whole’ field in proper perspective, it must not be imagined that the laboratory and clinical standpoints are incompatible or mutually exclusive. Sir GEORGE NEWMAN pointed out that all sound clinical work is’ research and pleaded for a more intimate assoel’ation between the workers in the laboratory and those in the wards ; and though Sir A. E. WRIGHT and Sir JAMES MACKENZIE clearly see the weak points of research restricted to the wards or to the laboratory respectively, it is obvious that the two methods are essential, and - that they are complementary to eachother. Both these teachers
out of every five are incorrect, it is most important that they should be carefully verified. This is the function of the research worker and it should be done by means of experiment; although everyone is convinced that he is equally fitted both to form and to test generalisations, it is the skilled laboratory man to whom this duty should be, allotted, in preference to the clinician, the statistician, or others. To ensure efficiency, this researcher must be specially trained, with a permanent post in a laboratory close to a hospital, and be a whole-time worker. Further, the whole-time principle , should be applied throughout the research organisation-to those who direct and plan, as well as to those who carry, out the work.
provided
Acute Rheumatism. and Chorea. IT is a striking commentary on the difficulties of medical research that in quite ordinary infective and infectious diseases the aetiology and pathology remain, most obscure. We need only instance many common exanthematous fevers and acute rheumatism. In this week’s issue of THE LANCET we publish two recent and important papers dealing with different aspects of the problem of, acute rheumatism and its clinical manifestations ; in both of them a strong plea is made for more concentrated and general study of the subject. The first paper, by Dr. F. J. POYNTON, Dr. DONALD, PATERSON, and Dr. J. C. SPENCE, was read, before, the Medical Society of London, and appears on p. 1086. It contains a careful analysis of 172, cases
or
acute
rneumatism
12 years of age admitted
in
during
cnnaren
unaer-
12 months into
the wards of the Hospital for Sick Children, Great Ormond-street. These cases afford a remarkable securing sound first illustration of serious results of the disease. Of of so as to
emphasise importance principles for the organisation research ensure orderly, systematic, and successful ’re,sults. - the 172 cases observed by them nearly, 13 per cent. In a recent address at the Victoria Infirmary, died, over 17 per cent. became complete invalids, 30 per cent. had organic heart disease Glasgow, Sir JAMES MACKENZIE, who admitted that and nearly three months after the end of the as the outcome of clinical experience he regarded when examined If the results were so serious after considered. year research from ’ an aspect different from’ that a period, it is brief easy to conceive that so, of "those specifically engaged upon ’it, described and the economic loss: effects pathological the the following as the guidingprinciples ’ of’ medical research: the recognition of the onset entailed by them are extremely serious. A con-, siderable portion of the paper is devoted,,to the of disease with - all the circumstances, and the
of
the symptoms, which should then’ be arranged into groups, so that a disease can be separated from others superficially, alike or previously ’ regarded as identical. Thus clinical methods first prepared the way and defined’ the problem of malaria, which by special methods the bacteriologist then solved and so achieved’ one of the most brilliant successes in the annals of medicihe, particularly in its most that of prevention. Although malaria may, as Sir JAMES MACKENZIE points out, be an exceptional instance, it admirably illustrates the manner in which these two forms of research should be combined, and Sir A. E. WRIGHT appears to endorse the underlying principle. He insisted that isolated observations are easily made and accumulated, but that the difficulty lies in arriving at solid generalisations. Although most men flatter themselves that they have this gift, it is really an attribute of superior intellect, such as that ’of the late Sir WILLIAM JENNER, who differentiated typhus from enteric fever. Such generalisationsare of slow growth, and, as it seems safe to estimate that four
careful observation of
important bearing-
1 J. Mackenzie : Glasgow Med. Jour., 1920, xciv.,
257.
of chorea ; this condition was present in 60 per cent., of the 172 cases. In 37 out of these 104 cases of chorea there was no other evidence of rheumatism, but the writers believe it best to, every case due to a rheumatic origin unless there is convincing evidence to th,e contrary. They maintain that of the three
subject
104, or
consider
cardinal manifestations of rheumatism-heart
affections, arthritic symptoms, and chorea-the last-named is the most frequent as a solitary symptom-group. They claim that there are two types of rheumatic attacks in the young-one, the more fatal, with tonsillitis, arthritis, and morbus cordis ; the other, more chronic, with chorea and endocarditis, often resulting in mitral stenosis. This paper shows a close observation of this disease, and gives a careful analysis of symptoms and their significance. Two points of interest not generally mentioned in text-book descriptions are the association of
severe
stiff-neck with serious heart
disease, and the striking taciturnity of cases,with virulent involvement of the heart. The second paper, which appears in full on the Bradshaw lecture delivered p. 1081, is before the Royal College of Physicians of London
THE LANCET. LONDON: SATURDAY, NOVEMBER 27, 1920.
A Broad
Conception
1103
CONCEPTION OF MEDICAL RESEARCH.
of Medical
Research. As the first recipient of the Royal Society of Medicine’s gold medal, generously endowed by a Fellow who prefers to remain anonymous, Sir A. E. WRIGHT appropriately gave an address on Medical Research on Armistice day. This subject has, of course, been, much discussed in connexion with medical reconstruction, notably by Sir JAMES MACKENZIE, who referred again to it in an inaugural lecture on Oct. 19th at Glasgow,’ and by Sir GEORGE NEWMAN in his well-known reports. These three authorities may fairly be taken as spokesmen of the laboratory, the clinical, and the educational points of view. While as an onlooker the last named is in a better position to survey the whole’ field in proper perspective, it must not be imagined that the laboratory and clinical standpoints are incompatible or mutually exclusive. Sir GEORGE NEWMAN pointed out that all sound clinical work is’ research and pleaded for a more intimate assoel’ation between the workers in the laboratory and those in the wards ; and though Sir A. E. WRIGHT and Sir JAMES MACKENZIE clearly see the weak points of research restricted to the wards or to the laboratory respectively, it is obvious that the two methods are essential, and - that they are complementary to eachother. Both these teachers
out of every five are incorrect, it is most important that they should be carefully verified. This is the function of the research worker and it should be done by means of experiment; although everyone is convinced that he is equally fitted both to form and to test generalisations, it is the skilled laboratory man to whom this duty should be, allotted, in preference to the clinician, the statistician, or others. To ensure efficiency, this researcher must be specially trained, with a permanent post in a laboratory close to a hospital, and be a whole-time worker. Further, the whole-time principle , should be applied throughout the research organisation-to those who direct and plan, as well as to those who carry, out the work.
provided
Acute Rheumatism. and Chorea. IT is a striking commentary on the difficulties of medical research that in quite ordinary infective and infectious diseases the aetiology and pathology remain, most obscure. We need only instance many common exanthematous fevers and acute rheumatism. In this week’s issue of THE LANCET we publish two recent and important papers dealing with different aspects of the problem of, acute rheumatism and its clinical manifestations ; in both of them a strong plea is made for more concentrated and general study of the subject. The first paper, by Dr. F. J. POYNTON, Dr. DONALD, PATERSON, and Dr. J. C. SPENCE, was read, before, the Medical Society of London, and appears on p. 1086. It contains a careful analysis of 172, cases
or
acute
rneumatism
12 years of age admitted
in
during
cnnaren
unaer-
12 months into
the wards of the Hospital for Sick Children, Great Ormond-street. These cases afford a remarkable securing sound first illustration of serious results of the disease. Of of so as to
emphasise importance principles for the organisation research ensure orderly, systematic, and successful ’re,sults. - the 172 cases observed by them nearly, 13 per cent. In a recent address at the Victoria Infirmary, died, over 17 per cent. became complete invalids, 30 per cent. had organic heart disease Glasgow, Sir JAMES MACKENZIE, who admitted that and nearly three months after the end of the as the outcome of clinical experience he regarded when examined If the results were so serious after considered. year research from ’ an aspect different from’ that a period, it is brief easy to conceive that so, of "those specifically engaged upon ’it, described and the economic loss: effects pathological the the following as the guidingprinciples ’ of’ medical research: the recognition of the onset entailed by them are extremely serious. A con-, siderable portion of the paper is devoted,,to the of disease with - all the circumstances, and the
of
the symptoms, which should then’ be arranged into groups, so that a disease can be separated from others superficially, alike or previously ’ regarded as identical. Thus clinical methods first prepared the way and defined’ the problem of malaria, which by special methods the bacteriologist then solved and so achieved’ one of the most brilliant successes in the annals of medicihe, particularly in its most that of prevention. Although malaria may, as Sir JAMES MACKENZIE points out, be an exceptional instance, it admirably illustrates the manner in which these two forms of research should be combined, and Sir A. E. WRIGHT appears to endorse the underlying principle. He insisted that isolated observations are easily made and accumulated, but that the difficulty lies in arriving at solid generalisations. Although most men flatter themselves that they have this gift, it is really an attribute of superior intellect, such as that ’of the late Sir WILLIAM JENNER, who differentiated typhus from enteric fever. Such generalisationsare of slow growth, and, as it seems safe to estimate that four
careful observation of
important bearing-
1 J. Mackenzie : Glasgow Med. Jour., 1920, xciv.,
257.
of chorea ; this condition was present in 60 per cent., of the 172 cases. In 37 out of these 104 cases of chorea there was no other evidence of rheumatism, but the writers believe it best to, every case due to a rheumatic origin unless there is convincing evidence to th,e contrary. They maintain that of the three
subject
104, or
consider
cardinal manifestations of rheumatism-heart
affections, arthritic symptoms, and chorea-the last-named is the most frequent as a solitary symptom-group. They claim that there are two types of rheumatic attacks in the young-one, the more fatal, with tonsillitis, arthritis, and morbus cordis ; the other, more chronic, with chorea and endocarditis, often resulting in mitral stenosis. This paper shows a close observation of this disease, and gives a careful analysis of symptoms and their significance. Two points of interest not generally mentioned in text-book descriptions are the association of
severe
stiff-neck with serious heart
disease, and the striking taciturnity of cases,with virulent involvement of the heart. The second paper, which appears in full on the Bradshaw lecture delivered p. 1081, is before the Royal College of Physicians of London