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A Broad Conception of MedicalResearch.

A BROAD CONCEPTION OF MEDICAL RESEARCH.

THE LANCET.

LONDON: SATURDAY, NOVEMBER 27, 1920.

As the first recipient of the Royal Society ofMedicine’s gold medal, generously endowed by aFellow who prefers to remain anonymous, Sir A. E.WRIGHT appropriately gave an address on MedicalResearch on Armistice day. This subject has, ofcourse, been, much discussed in connexion withmedical reconstruction, notably by Sir JAMESMACKENZIE, who referred again to it in an inaugurallecture on Oct. 19th at Glasgow,’ and by Sir GEORGENEWMAN in his well-known reports. These threeauthorities may fairly be taken as spokesmen ofthe laboratory, the clinical, and the educationalpoints of view. While as an onlooker the lastnamed is in a better position to survey the whole’field in proper perspective, it must not be imaginedthat the laboratory and clinical standpoints areincompatible or mutually exclusive. Sir GEORGENEWMAN pointed out that all sound clinical work is’research and pleaded for a more intimate assoel’a-tion between the workers in the laboratory andthose in the wards ; and though Sir A. E. WRIGHTand Sir JAMES MACKENZIE clearly see the weakpoints of research restricted to the wards or to thelaboratory respectively, it is obvious that the twomethods are essential, and - that they are comple-mentary to each other. Both these teachersemphasise the importance of securing sound firstprinciples for the organisation of research so as toensure orderly, systematic, and successful ’re,sults. -In a recent address at the Victoria Infirmary,

Glasgow, Sir JAMES MACKENZIE, who admitted thatas the outcome of clinical experience he regardedresearch from ’ an aspect different from’ thatof "those specifically engaged upon ’it, describedthe following as the guiding principles ’ of’medical research: the recognition of the onsetof disease with - all the circumstances, andcareful observation of the symptoms, whichshould then’ be arranged into groups, so that adisease can be separated from others superficially,alike or previously ’ regarded as identical. Thusclinical methods first prepared the way and defined’the problem of malaria, which by special methods the bacteriologist then solved and so achieved’ oneof the most brilliant successes in the annals of medi-cihe, particularly in its most important bearing-that of prevention. Although malaria may, as SirJAMES MACKENZIE points out, be an exceptionalinstance, it admirably illustrates the manner inwhich these two forms of research should be com-bined, and Sir A. E. WRIGHT appears to endorse theunderlying principle. He insisted that isolatedobservations are easily made and accumulated,but that the difficulty lies in arriving at solidgeneralisations. Although most men flatter them-selves that they have this gift, it is really anattribute of superior intellect, such as that ’of thelate Sir WILLIAM JENNER, who differentiated typhusfrom enteric fever. Such generalisations are of slowgrowth, and, as it seems safe to estimate that four

1 J. Mackenzie : Glasgow Med. Jour., 1920, xciv., 257.

out of every five are incorrect, it is most importantthat they should be carefully verified. This isthe function of the research worker and it shouldbe done by means of experiment; although every-one is convinced that he is equally fitted both toform and to test generalisations, it is the skilledlaboratory man to whom this duty should be,allotted, in preference to the clinician, the statis-tician, or others. To ensure efficiency, thisresearcher must be specially trained, providedwith a permanent post in a laboratory close to ahospital, and be a whole-time worker. Further,the whole-time principle , should be appliedthroughout the research organisation-to thosewho direct and plan, as well as to those who carry,out the work.

Acute Rheumatism. and Chorea.IT is a striking commentary on the difficulties

of medical research that in quite ordinary infectiveand infectious diseases the aetiology and pathologyremain, most obscure. We need only instancemany common exanthematous fevers and acuterheumatism. In this week’s issue of THE LANCETwe publish two recent and important papersdealing with different aspects of the problem of,acute rheumatism and its clinical manifestations ;in both of them a strong plea is made for moreconcentrated and general study of the subject. Thefirst paper, by Dr. F. J. POYNTON, Dr. DONALD,PATERSON, and Dr. J. C. SPENCE, was read, before,the Medical Society of London, and appears onp. 1086. It contains a careful analysis of 172,cases or acute rneumatism in cnnaren unaer-

12 years of age admitted during 12 months intothe wards of the Hospital for Sick Children, GreatOrmond-street. These cases afford a remarkableillustration of serious results of the disease. Ofthe 172 cases observed by them nearly, 13 per cent.died, over 17 per cent. became complete invalids,and nearly 30 per cent. had organic heart diseasewhen examined three months after the end of theyear considered. If the results were so serious afterso, brief a period, it is easy to conceive thatthe pathological effects and the economic loss:entailed by them are extremely serious. A con-,siderable portion of the paper is devoted,,to thesubject of chorea ; this condition was present in104, or 60 per cent., of the 172 cases. In 37 out ofthese 104 cases of chorea there was no otherevidence of rheumatism, but the writers believeit best to, consider every case due to a rheumaticorigin unless there is convincing evidence toth,e contrary. They maintain that of the threecardinal manifestations of rheumatism-heartaffections, arthritic symptoms, and chorea-thelast-named is the most frequent as a solitarysymptom-group. They claim that there are twotypes of rheumatic attacks in the young-one,the more fatal, with tonsillitis, arthritis, and morbuscordis ; the other, more chronic, with chorea andendocarditis, often resulting in mitral stenosis.This paper shows a close observation of this disease,and gives a careful analysis of symptoms and theirsignificance. Two points of interest not generallymentioned in text-book descriptions are the asso-ciation of severe stiff-neck with serious heartdisease, and the striking taciturnity of cases,withvirulent involvement of the heart.The second paper, which appears in full on

p. 1081, is the Bradshaw lecture deliveredbefore the Royal College of Physicians of London

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by Dr. CECIL WALL on " Chorea." After an

exhaustive and critical analysis of the clinicalmanifestations of this condition Dr. WALL hasdeveloped an ingenious explanatory hypothesis.For him chorea is a symptom-complex rather thana nosological entity, a distinction with which fewwould at present disagree. He points out that,although the rheumatic origin of ordinary choreais now almost universally accepted, actual proofcannot be forthcoming until the ætiological agentof rheumatism has been conclusively established andits relation to chorea demonstrated. The figures hequotes show that in England and Wales in 1917 105’6per 1000 of the deaths from all causes were due toorganic heart disease, while 86’4 per 1000 were dueto pulmonary tuberculosis and 82’5 to cancer. Thetwo latter conditions are the object of organisedand subsidised research; it seems almost incrediblethat " no attempt has yet been made toward co!5rdi-nated investigation into the chief aatiological factorin the commonest cause of death." Dr. WALL’Scareful study of the individual symptoms and thecharacter of the movements should be carefullyfollowed in order to judge of the evidence onwhich he bases the following hypothesis as to theirgenesis ana nature. ne moaesriy aisciaims priormyor originality for this hypothesis and shows thatit was adumbrated in 1784 by PROCHASKA andfirst definitely put forward by WARNER in 1887.Dr. WALL believes that chorea is due " to a rever-sion or regression to a functional capacity charac-teristic of an earlier stage of development," andmaintains that choreic movements are in theiressentials like those of the microkinesis ofchildren, and are due to diminished control

owing to impairment of certain cerebral centres,presumably cortical in situation. This attractivehypothesis is developed and discussed by Dr. WALLwith great skill, and seems to offer an intelligibleexplanation of these peculiar movements.

If some concerted action could be taken in regardto rheumatism far-reaching results might accrue.There is work here for bacteriologist, clinician,hygienist, and political economist. The greatergravity and frequency in the class treated in

hospitals compared with other classes is a pointbrought out by Dr. POYNTON and his colleagues.Some of the problems which might be collectivelystudied were well illustrated in a paper publishedin THE LANCET. of July 24th by Dr. CAREY F.COOMBS on Incidence of Fatal Rheumatic HeartDisease in Bristol from 1876-1913. The materialfor study abounds, the prospects of national benefitfrom such a research are good-all that is necessaryis some official stimulation and coördination andthe necessary financial endowment.

Prescribing and Dispensing.THE law relating to the prescribing and dis-

pensing of medicine may be regarded as havingreached a stage when the former conditions arebeing gradually but inevitably replaced. There isa growing tendency to advocate the completeseparation of the two procedures, and it is probablethat in the near future some legislative measuresmay be taken to produce this result. The growthof panel practice prepared the way for such achange, since it regularised the conditions ofremuneration, which, it was hoped, would be satis-factory both to the medical profession and to thedispensing chemists. So far as medical men areconcerned it is probable that this separation of

work will be cordially welcomed by some.since they will thus be relieved from thelabour of dispensing after rounds of visiting.There is no doubt that after a long and possiblyarduous day’s work the procedure of dispensingand the necessary bookkeeping are very irksome tosome, and they are rendered all the more irksomeby the feeling of responsibility medical men musthave in regard to absolute accuracy. Casual atten-tion is not sufficient; no care can be too great, andthe scrupulous exactitude which is routine to thetrained pharmacist is only got by the medical manthrough unremitting watchfulness. And medicalmen, to whom the pharmacological side makes noparticular appeal, find the task of dispensing espe-cially distasteful. But it must be remembered thatthere are others of a different way of thinkingwho will not welcome compulsory divorce fromwhat they regard as an integral part of medicalpractice.The necessity for order and attention in all

pharmacological procedure has recently beenmade apparent by circumstances in the course ofthe Kidwelly poisoning case which have been so-

widely advertised in sensational reports that theyrequire no detailed reference. The evidence inthe course of this case has given the Council ofthe Pharmaceutical Society of Great Britain anopportunity of calling the attention of the PrivyCouncil, the Ministry of Health, and the HomeSecretary to the advisability of appointing a com-mittee to inquire as to what changes, if any. arenecessary in (1) the law relating to the prescribingand dispensing of medicines; (2) the supply anduse of poisonous weed-killers. With the second ortrade question the medical profession is not directlyconcerned, for interference would probably onlytake the form of diverting the channels throughwhich these articles can be procured. But in

regard to the first point, it is the opinion ofthe Council that the Kidwelly case has pro-vided striking evidence in favour of separatingthe functions of prescribing and dispensing inthis country, as in many countries abroad. TheCouncil of the Pharmaceutical Society, more-

over, indicate clearly the desire not only thatmedical men should cease to dispense, but alsothat dispensing chemists should cease to prescribe.This is an admission of the possibility of dangerin a direction which has often been noted bymedical men, but the extent of the mischief hashardly been realised by the public. If from thedisassociation of prescribing and dispensing thepublic learns that a doctor should not be consultedmerely to obtain medicine, undoubtedly there willbe professional gain, but stronger arguments inIavour oi separation are auoraea oy tne practice 01

prescribing by pharmacists in whose curriculum thetreatment of disease finds no place. We know verywell that some pharmacists do not prescribe at all, andthat the others, with but few exceptions, prescribeonly for simple ailments; but there, unfortunately,is where the peril lies. The prescribing chemist,even though he sets himself this limitation, mayat any moment encourage a false sense of security ina case of phthisis by administering a cough mixture.and thus the critical early months go by; or he maytreat a diphtheritic throat as a simple tonsillitisuntil it is too late to administer antitoxin usefully.The Dangerous Drugs Act introduces numerous

regulations which will tend to favour the separa-tion of prescribing and dispensing. This Act isthe necessary outcome of the International OpiumConvention, which was signed at the Hague in