SOME
REFLECTIONS
RESEARCH IN
ON
MEDICINE.* BY
F.
J.
Poynton, M.D., F.R.C.P., Consulting Physician to University College Hospital; to Great Ormond Street Children's Hospital; and to Winford Orthopaedic Hospital.
Ladies
Gentlemen, for my
and
sake of medicine I intellect such
its
as
hope
his
you
was so
Galens, for
an
commanding that eventually tended
to
become
an
to progress rather than to assist its advance. "
Research
"
for my and shall from time to time illustrate it from
I have chosen
subject,
sake and for the
not all
are
unquestioned authority
obstacle
own
the ancient mistake.
history
I
am
Reflections
on
But be under
of rheumatism.
not
supposing
or
no
that you sometimes called
wishing
should all become what are Researchers." A great part of my professional life ^vas spent teaching general medicine to students with '
a
view
to the most
important
task of
general practice.
The great work of doctors is done in ordinary general practice, not in whole-time research ; but it is, I think, a
great advantage to preserve some of the characteristics ?f the research mind, whatever line you may take up. These prevent one from getting too much in a groove, arid from *
?n
becoming
that rather dreadful person
An address delivered to the 4th May, 1937.
Tuesday, 127
"
Galenicals
"
in the
University
a
of Bristol
128
Dr. F. J. Poynton
self-made
authorit}' on a subject upon which doctors only know surprisingly little.
wisest
the
It must have struck you how strange it is that when there is a difficult case frequently an able man of many
years' experience is baffled as much as you are yourselves: that is supposing you have escaped from that first evidence of ignorance which leads you when a clinical clerk of two months' standing to believe that you know more than the experienced. Even a resident may be a very trying individual with his air of importance, and I speak from a long experience of residents, mostly good, some moderate, a few definitely bad. When I analyse my bad ones they have been either lazy or have continually insisted upon teaching me. I say continually, for there is no sensible physician who cannot learn something from a younger mind. There are very different ideas about research, and " the word genius" frequently crops up over this It is pursuit. I do not attempt to define
genius.
commonly discovered, we know, after the individual is dead, but I will give you my idea of most
genius.
A
man
watches
a
small
boy blowing
a
fine
soap bubble, and argues from this that the soapy medium forms the envelope of that bubble and that the heated air inside
causes
it to float.
He takes
a
small paper bag, fills it with hot air, ties the neck and sees it rise in the air. He perseveres and makes a balloon 35 feet high, 110 feet in circumference?
weighing
500
lbs., and demonstrates that it also will
ascend in the air. full it
pulls
so
Then he notices that before it
hard to ascend that it
ropes to hold it down.
Accordingly
requires
men
he argues it
ie
and "Will
Some Reflections
on
Research
in
129
Medicine
something up, and eventually sees human beings riding through the air and has laid the foundation of take
aeronautics. He
capacity ?f
shown
has for
visualized
seen
at the best
the
only
one
infinite feature
did not see, he has possibly result from his
what
what
"
than
more
taking pains," He has
genius.
much
we
might observation, turning neither to the right nor left has, step by step, rationally developed his discovery. Most geniuses are simple-minded, because every step ?f that epoch-making discovery was simple when you come to think of it to-day and to look back and
?n
it.
Research in medicine is ?f the
vastly more
difficult because
of human life and disease,
great complexity but the general principles
are
the
same?some
little
suddenly explained, some scattered areas of knowledge drifting along by themselves suddenly linked together by a penetrating mind, some new discovery not directly connected with Medicine suddenly recognized as a starting-point for a new medical development. Rheumatism was thought by the ancients to be a Peccant humour or rheum spreading down from the secret missed for
brain,
years
but Radulfe in the thirteenth
his attention
century focused
joints and muscles and spoke of gout," which Aretseus in the second century had
^ith.
some
on
the
truth observed
none
stood. The peccant humour
but the
forms
"
was
under-
rheum had now, you see, Then with the joints.
or
become something wrong -^allonius in the seventeenth century arthritis
gods
noticed that
gouty, and called these other
rheumatism."
not
acute
130
Dr. F. J. Poynton Then old bones
up which showed that arthritis was not always aGute bat was sometimes very chronic, and this led to Sydenham trying to evade this
dug
were
difficulty by calling
this chronic form
rheumatism."
Storck
for
thought,
Next
but that there
the French
what more
a
only an arthritis complications. Then
not
was
visceral
were
scorbutical of new line
examinations he showed
by post-mortem
in 1762 that rheumatism
during
started
"
Revolution
Beauvais
recognized
call rheumatoid arthritis from among the chronic forms of arthritis. we
In
1789
mark
Edward Jenner?a content
you?not
general practitioner,
only
with
vaccination,
recorded heart disease and rheumatism. the
genius
and in
of Lsennec with the
1836
the
by establishing with
French
great the
Then came
stethoscope in 1819, physician Bouillard,
association
of
carditis
acute
rheumatism, left in continental literature the Bouillard's
term
disease
for
acute
rheumatism
of
childhood.
Sydenham, writing on chorea, and a little earlier Stoll in 1789, began to show us its association with rheumatism, and Begbie in 1847 maintained it was not due to heart caused
by
disease, but with heart disease
genius arrived named Pasteur,
for
nearly forty rheumatism, especially be due to infection
fringe
was
years the idea that children's rheumatism,
of
understanding
we "
humour
has ceased
are
more
flowing
"
rheum
"
or
some
might
over
than
rheumatism":
sometimes think the ancient "
worked at all
being
Yet do not think
world.
also
rheumatism.
Another French and
was
on
the the
indeed I "
peccant
down from the brain of
Some Reflections
Research
on
the rheumatic, and is
brains of all of
by
who
us
Medicine
131
flowing down from the fighting over what is meant
now are
rheumatism and what In
in
are
its
causes.
spite of this pathetic conclusion, I
cannot
help
that all of you who have listened to these stories of the air balloon and of rheumatism must feel
feeling a
has
chord
sympathetic
touched
been
with
our
literature, the Penguin books, price 6d., in
modern
^hich you trace the activities of the detective rival amateur genius discovering the murderer. When
you examinations
naturally moment
as
facts. an
necessity
to
you
a
pass are
looked upon at the You must have facts to achieve
concerned with what
in
success
absolute
an
medicine
studying
are
or
are
and
you must pass fact is the end of its research.
examination,
examinations, but a When I say a to-and-fro
murmur
heard
over
the aortic
is evidence of aortic regurgitation, and prove it to you by a post-mortem examination, the research on that particular point is at an end, for it has become
cartilage
^
fact.
The
"
cram
"
books
on
medicine?mind, I do
decry them?largely consist in a collection of bottled facts, and one great objection to repeated examinations is the danger that your mind is deadened by learning facts, that is you are continually reaching
not
full stops.
Perpetual teaching, exiled,
or
"spoon feeding"
from the earliest moments in the
not assist the research
through
the
spirit.
examination
your view of it to
Say I think you is the
point you
me,
have want.
of
as
it is
wards, does
Now if you blunder and present case a
naturally enough I might missed the point here, this But you
have, nevertheless,
Dr. F. J. Poynton
132 undertaken
a
research, and like everyone beginning
research you may have missed the essential, but you have strengthened your intelligence, not dulled it or kept it stationary. to
research and
There is into
a
a
even
curious idea that
laboratory
to research is
already
may not be. outlined but
detail.
That is
may
or
work of
someone
a
who drifts
superior being.
He
He may carry on some work needing to be studied in more
superior to the confirming some new already made but requiring more but it is not
good work,
someone
in the wards
clinical observation confirmation.
ending
This is often called
"
hack work."
I
don't call it hack
mysterious superior being
or
work, but useful work, though not marvellous work. This, then, is no
because he is in
marvellous than
more
laughs It is
a
laboratory,
his friend the
he is not
clinician he
at.
clearly, then,
most
important that we recognize laboratory research,
that there is clinical research and and
post-mortem evidence
too when that is
needed
keep us steady. There is no place on either side for antagonism. It must be remembered that clinical research may anticipate laboratory research, although the exact explanation of the clinical observation may have to await the laboratory investigator. I knew the great children's physician, Dr. Cheadle, to
very well, and he told me that as a result of his travels in Canada he had seen and learnt much about scurvy
returning to England he found doctors terribly puzzled over a condition in infants brought about by patent foods. No one knew how to He from his treat it or what it really was in nature. in
adults, and that
on
observations and research into the scurvy of adults
Some Reflections at
once
Jt
by
on
Research
realized it to be scurvy in fresh foods.
He insisted that there
was
infancy, a
133
Medicine
in
and he cured
lack of
something
which he called the antiscorbutic element in the patent
foods,
because he had studied adult scurvy and its causation. Now you all recognize that element as
Vitamin C,
but many infants had been saved before you knew this or I knew it, and one of the duties of a
doctor is
to
Vitamin
C.
save
life,
even
if he cannot
give
the
name
The reverse, of course, occurs. I have only to Mention insulin and many other instances will occur to you. I am putting aside for simplicity's sake any question of the financial side of our subject, though I would Remind you that the great investigators have often Worked in very small laboratories, and that a Magnificent laboratory does not always mean good
Work, though it is It
is
useless
a
great
to
lay
asset to
down
good laws
work. for
the
born
He or she stands apart from us, with that curious gift of seeing something that seems new ; that outstanding patience against failure or derision,
investigator.
because
he knows that it is
something
new, and that
concentration on the goal ahead. He may not succeed he may be wrong, but he leaves a track of some kind
0r
Which is of value, and by his mental power trains others who may surpass him in results.
^variably stimulating aiid
obey
their
they
are
Now when the laboratory investigator,
Worker, begins
are
in the boldness of their outlook
of purpose, but own laws.
tenacity
Such minds
to scoff at and deride the
minds which
as a
research
clinician he
Dr. F. J. Poynton
134
I have been a pathologist, a way. bacteriologist, and a clinician in my time, and I have worked shoulder to shoulder with each type, though I is
in
bad
a
became
clinician
a
eventually
I admire all
human side.
because I loved
types,
but when
a
the
vaccine
laboratory undertakes to cure a specialist living case of malignant endocarditis, and after his injections the temperature slowly falls and the patient dies, and in
he does not
a
post-mortem examination
to the
come
;
further, when he is content to say if he had commenced the treatment sooner the patient would have lived, X think
badly
of him.
what the clinician was
the
sign
Why
?
Because he did not know
knows, that the fall in temperature
patient's resistance was exhausted, partial success of a vaccine. If he had
that the
and not of the
autopsy he would have seen the impossibility of his claim, but as it is he returns to his come
the
to
laboratory believing bad way. In this
laboratory
in
a
partial
success, and he is in
a
you see two instances of research, the research which I do not criticize, and the
case
clinical research which led the
physician to recognize from his knowledge of malignant endocarditis and from his knowledge of his patient that the fall of temperature was premonitory to death. The weak point was the ultimate failure in research of the laboratory investigator in not facing the findings of The physician could the post-mortem examination. also have told him that he had the
earliest
moment
endocarditis and had
If, however, at
some
a
of
even
physician
future time
a
seen
vaccines used at
detection then
seen
malignant
them fail.
possibility that might be discovered
denied the
vaccine
of
Some Reflections
on
Research
Medicine
in
135
which would be successful, he would be speaking without the requisite knowledge of the possibilities of
laboratory lines,
research, and would be also moving
because he could not
laboratory
bad
know the future of
research.
Take another care
possibly
on
A
case.
physician
of anaemia which he
a case
has under his
assumes can
be cured
with
massive doses of iron, but the case does not improve. He is persuaded to call in from the laboratory
expert upon examination of the blood, who at once points out that it is a pernicious anaemia. Here the physician has failed in his research mind, and has
an
assumed
that
once
laboratory To
stress mind as
are
from
his
own
experience
to
laboratory research worker could be an erroneous assumption from his
researches.
recapitulate on
knew
that the
something Prove at
he
at this
point.
I have been
laying
the belief that the essentials of the research to be found in
wards,
at the
bedside,
as
well
laboratories; that the various research minds should try to keep in touch with the main object? in
the advancement of medicine?and not become aloof
from
one
ttiind is guided
another; and that the outstanding research one
by
which makes its 'own laws and is not
ours;
and, lastly, that such minds have
a
stimulating
effect upon us by their peculiar quality and power to make us think. You may ask: How can the research mind help lri
every-day work ? It can help from the first. For instance, in reminding you that you are not studying a pneumonia, but a case of pneumonia, a human being suffering from pneumonia. Then you begin to realize the truth, for you find yourself inquiring in your mind,
136
Dr. F. J. Poynton
why
did this
do well and that
case
one
do
badly
You
?
led to research away from the pneumonia into the type of pneumonia, into the influence of age, of alcoholism, of overwork and under-nourishment and are
results, after the necessary experience brought alone by time, in making the competent doctor, the practitioner who becomes It is this habit of mind that
so on.
is sound.
trusted because his
thoroughly
judgement Year after year, unconsciously perhaps, he researching not only into pneumonia, but
has been into how
pneumonia and other illnesses may affect this
or
that
individual. I could
the
type of mind when I was examining. When, for example, I asked some question upon see
treatment, and the case
"
came,
If I had
earlier I should have advised immediate
but I
am
not certain that
The
great." was
answer
the
particular
same
recognized
from the
weak,
a
too
being
old,
had altered
or some
qualified as
cases
and in
some some
In this
There is
no
answer
I
doubt that
curious
point, some unexpected happening
assists the research mind.
over
he had
undertaking of
practice you may laugh
I have
:
complication had
student the rather wearisome
about one's notes
first, but the examinee had
research mind.
noting down each day interesting comment, or
operation,
the risk will not be too
the issue doubtful.
arisen
making recognized the
or
this
condition under consideration
that the human
become too
when
now
seen
mine, but
they
When
your old served their
over
purpose. We must realize that the research mind is to some extent adventurous and takes the risks of adventure,
and to
me
it has
seemed that when
a
particular
Some Reflections
physician
keep lose
asks
on
Research
in
137
Medicine
questions of students that those who
well in the back
row
to avoid
answering
them
thereby.
You may be
do
some
quite sure of this. If you eventually research, so often called original?but so
as you will be surprised to find actually original have to face up to criticism and to cultivate will ?you a placid, I don't say a pacific, mind to carry you along. If the work is important and you believe sound
rarely
you must defend it, but if from studentship feared criticism and making some mistakes have you
certainly
you will not
easily keep
your
equanimity later,
and
you may even turn tail. There is much to be learnt, of course, in laboratory "training just as there is in surgery?much accuracy, and
in
some
instruments, can
cases
knowledge
of
handling
on, before the actual investigation Some minds naturally undertaken.
and
be
much
so
safely enough prefer the wider, more philosophical nature of niedicine, or the practical details of preventive medicine, hut they are not safe from researoh. You
never
know, in whatever branch of the
Profession you are, whether opportunities may not arise which put you into the position of making some useful contribution.
This leads
consideration, the
putting
published form.
art
of
This is also
a
type
me
to another
your work into of research. It is
a
research into the minds of those whom you think ^ill read your work. Do not suppose I am going to
advise you to study my writings for this purpose. I have written three books, numerous lectures and a dreadful number of medical articles, and I was told
recently by
the candid friend and the
gentle
critic that
Dr. F. J. Poynton
138 "
I wrote
I
journalese."
by
am
nature not
easily
moved, and love the humorous side of things, and my retort
an
was
easy
one.
three books
and
published send?reprints of your
It are
"
When you have asked for?I do not mean
was :
lectures
come
and
see me
again
and talk it over."
great pitfalls in writing. One is, to suppose the reader knows the subject as well as you do yourself. There
are
Another to
use a
number of
only a few are necessary. complicated graphs in great reader
who
is
not
long
scientific words when
Another to suppose that numbers can appeal to a
acquainted
with
complicated
diagrams. Another to presume that everyone who may not agree with your new and perhaps debatable conclusions is a fool. Even if I am a fool I do not like to
feel
it, and the enemy bides his time
to
strike
back. A summary at the end of your paper should avoid " the obvious. Such as this (No. 1) : We have shown that rheumatism is
a common
disease."
We all know "
already. Or an ending such as this (No. 2): We have investigated x number of cases for such and such a point, but it will require many more before we can We decide upon the real interpretation." (No. 3): publish these results as a preliminary step." Why publish them if you want many more cases to prove the meaning of your point ? Why not wait and not trouble to inform the medical profession rheumatism I am very suspicious of & is a common disease. preliminary report, because so often one never hears It reminds me of showing a difficult the sequel. clinical case you cannot diagnose and never reporting later the fate of that case. Lastly remember : What that
"
"
Some Reflections
on
written is written."
be surprised if, in your view not
Research One often
in
Medicine
regrets this.
139 Don't
of accuracy, you may find understood, or garbled. Be patient.
spite
There is another
aspect of research,
interesting specialization, and tendency probably in the end complete specialization. It is a clear impossibility to investigate everything
?ne.
This
is
the
to
in medicine, but I do think this, that to realize
that
investigation
when
an
we
we narrow our
we
should
try
take up special lines of outlook on human illness,
and may lose a sense of proportion. We should be on guard lest we become fanatics. There are plenty of instances of able
people
who have found out
a
half-
truth?and it may be a valuable half-truth?and have then surrendered their research mind to fanaticism, ^lore and more is to be explained by this half-truth,
everything is to be explained. Such able niinds may become actually deranged. Doctors who have to teach students are much protected against this, for the student requires varied teaching. Again, those cail listen to other views are much protected. You can quite easily become a fanatic over rheumatism. You can become a fanatic over the bacteriology, the endocrines, the diet, the gold as a drug or as a reward,
Until at last
the local focus, the rheumatic diathesis, bee venom, the climate, the sympathetic system and allergy. How
not
can
you
prevent this danger
?
I think
by
shutting yourself up in the chamber in which your Particular idea is living, but by listening to the words ?f others living in other chambers, perhaps they also inclined to be fanatics. You say to me, "Malfunction ?f the endocrines explains all rheumatism." And I ask, " Does a child aged three with Still's disease or
140
Dr. F. J. Poynton rheumatoid arthritis suffer from endocrine
juvenile
"
I say to What is your proof of that ? All rheumatism is due to an infection." You
malfunction ? "
you,
"
"
What is rheumatism ? Even as Pilate say to me, " " " I What is truth ? If I am honest I say, said, "
And you reply, How, then, do " you know all rheumatism is due to an infection ? Signs of fanaticism appear sometimes early in a don't
really
know."
student's career, and I don't like to see it, because it grows with age. Fanatics, it is true, have done wonders in
great
human disease it is
balanced, yet has that is the
results,
complicated study of frequently the mind that is
causes, but I think in the more
some
great truth
often the
to make known?
that obtains far-reaching because it knows that this truth cannot be more
one
forced upon unwilling ears, but must wait for results which bring conviction. Lister held firmly to the great
principle
of
and
antisepsis,
he
won
his
continuous efforts to show that the results his
faith,
not
as a
fanatic,
but
as a man
who
way
by
justified saw
that
the truth must the
justify itself and not be thrust against unwilling, thereby increasing resistance to its
acceptance. One of the as a
result is of any use. We must admit that deal of research seems to be lost, but we have
to whether
great
great difficulties in research is the doubt
a
also to admit that
we
never
know when something
apparently lost and useless may not be found to be of value. Many a man has suffered the fate during life apparently useless. Later, when he is dead, some change in thought has occurred and the true value of his work is suddenly discovered. I do not think anyone can guard against this. It is the fate that of
finding
all his work
Some
Reflections
comes to
only
the
to
are
get
and interest of the
pleasure the
and
not realize how
long
give short time aids
a
time it
subject you wish example, requires
grasp of the Rheumatism, for a
investigate. ^ast two years' study before you can difficulties and the problems. Yet there is to
joy of
grimmer
adversary.
Some of you may to
the
individual
the
combating takes
141
Medicine
in
pioneers in all departments of life, and the
consolations
work
Research
on
to research
such
at
the
grasp a
to
tendency
subject beginner. It seems to me that the time is up before he has had a chance to know the outlines of the
to
on
a
a
subject, result,
and and
*niperfect spent
yet he is obliged, perhaps,
produces through
&!ves it up.
of his life A
upon research, It is
produce
real fault
some
a
very
Then, maybe, he considers he has
one.
enough
no
to
good
as
you
on
this
deal of can
investigation money is easily
guess.
and he wasted
It is inevitable.
interesting point for the philosopher to ground which has been already explored and supposed to have yielded all its usefulness should be again explored by a beginner. If it is very lrnportant ground I think yes, for though you may arrive at the same results, you may see things from a different angle to the forerunner, and as a result side bracks be started from the main track. a
very
consider whether
Some things
and
are
so
well
established,
so
certain,
so
thoroughly recognized that continual repetition helpful. They have become facts, and most 1Inportant ones, but not requiring continual repetition,
*s not
Unless there
are
some
side tracks to be learnt from
them. There are limits there is so much that is Tr
0L-
to
repetition, especially
new
when
to discover. L
Liv.
No. 204.
142
are
Some Reflections
on
Research
Medicine
in
We cannot escape from the fact that some minds not meant for research in laboratories, though the
individuals may believe they have this flair. " vision get into a groove and lose that
Soon "
they
which is
required, and as you will know when you get to middle age, though some outstanding minds do not weaken in vision, most, like the singer, find themselves driven to sing the old songs that were once attractive but are not
new.
The mind of
a
child does not remain with
most of us, but it is the mind of
original, because unfettered by clearly the essential.
a
child that is
custom it
sees
so
very
REFLECTIONS
RESEARCH IN
ON
MEDICINE.* BY
F.
J.
Poynton, M.D., F.R.C.P., Consulting Physician to University College Hospital; to Great Ormond Street Children's Hospital; and to Winford Orthopaedic Hospital.
Ladies
Gentlemen, for my
and
sake of medicine I intellect such
its
as
hope
his
you
was so
Galens, for
an
commanding that eventually tended
to
become
an
to progress rather than to assist its advance. "
Research
"
for my and shall from time to time illustrate it from
I have chosen
subject,
sake and for the
not all
are
unquestioned authority
obstacle
own
the ancient mistake.
history
I
am
Reflections
on
But be under
of rheumatism.
not
supposing
or
no
that you sometimes called
wishing
should all become what are Researchers." A great part of my professional life ^vas spent teaching general medicine to students with '
a
view
to the most
important
task of
general practice.
The great work of doctors is done in ordinary general practice, not in whole-time research ; but it is, I think, a
great advantage to preserve some of the characteristics ?f the research mind, whatever line you may take up. These prevent one from getting too much in a groove, arid from *
?n
becoming
that rather dreadful person
An address delivered to the 4th May, 1937.
Tuesday, 127
"
Galenicals
"
in the
University
a
of Bristol
128
Dr. F. J. Poynton
self-made
authorit}' on a subject upon which doctors only know surprisingly little.
wisest
the
It must have struck you how strange it is that when there is a difficult case frequently an able man of many
years' experience is baffled as much as you are yourselves: that is supposing you have escaped from that first evidence of ignorance which leads you when a clinical clerk of two months' standing to believe that you know more than the experienced. Even a resident may be a very trying individual with his air of importance, and I speak from a long experience of residents, mostly good, some moderate, a few definitely bad. When I analyse my bad ones they have been either lazy or have continually insisted upon teaching me. I say continually, for there is no sensible physician who cannot learn something from a younger mind. There are very different ideas about research, and " the word genius" frequently crops up over this It is pursuit. I do not attempt to define
genius.
commonly discovered, we know, after the individual is dead, but I will give you my idea of most
genius.
A
man
watches
a
small
boy blowing
a
fine
soap bubble, and argues from this that the soapy medium forms the envelope of that bubble and that the heated air inside
causes
it to float.
He takes
a
small paper bag, fills it with hot air, ties the neck and sees it rise in the air. He perseveres and makes a balloon 35 feet high, 110 feet in circumference?
weighing
500
lbs., and demonstrates that it also will
ascend in the air. full it
pulls
so
Then he notices that before it
hard to ascend that it
ropes to hold it down.
Accordingly
requires
men
he argues it
ie
and "Will
Some Reflections
on
Research
in
129
Medicine
something up, and eventually sees human beings riding through the air and has laid the foundation of take
aeronautics. He
capacity ?f
shown
has for
visualized
seen
at the best
the
only
one
infinite feature
did not see, he has possibly result from his
what
what
"
than
more
taking pains," He has
genius.
much
we
might observation, turning neither to the right nor left has, step by step, rationally developed his discovery. Most geniuses are simple-minded, because every step ?f that epoch-making discovery was simple when you come to think of it to-day and to look back and
?n
it.
Research in medicine is ?f the
vastly more
difficult because
of human life and disease,
great complexity but the general principles
are
the
same?some
little
suddenly explained, some scattered areas of knowledge drifting along by themselves suddenly linked together by a penetrating mind, some new discovery not directly connected with Medicine suddenly recognized as a starting-point for a new medical development. Rheumatism was thought by the ancients to be a Peccant humour or rheum spreading down from the secret missed for
brain,
years
but Radulfe in the thirteenth
his attention
century focused
joints and muscles and spoke of gout," which Aretseus in the second century had
^ith.
some
on
the
truth observed
none
stood. The peccant humour
but the
forms
"
was
under-
rheum had now, you see, Then with the joints.
or
become something wrong -^allonius in the seventeenth century arthritis
gods
noticed that
gouty, and called these other
rheumatism."
not
acute
130
Dr. F. J. Poynton Then old bones
up which showed that arthritis was not always aGute bat was sometimes very chronic, and this led to Sydenham trying to evade this
dug
were
difficulty by calling
this chronic form
rheumatism."
Storck
for
thought,
Next
but that there
the French
what more
a
only an arthritis complications. Then
not
was
visceral
were
scorbutical of new line
examinations he showed
by post-mortem
in 1762 that rheumatism
during
started
"
Revolution
Beauvais
recognized
call rheumatoid arthritis from among the chronic forms of arthritis. we
In
1789
mark
Edward Jenner?a content
you?not
general practitioner,
only
with
vaccination,
recorded heart disease and rheumatism. the
genius
and in
of Lsennec with the
1836
the
by establishing with
French
great the
Then came
stethoscope in 1819, physician Bouillard,
association
of
carditis
acute
rheumatism, left in continental literature the Bouillard's
term
disease
for
acute
rheumatism
of
childhood.
Sydenham, writing on chorea, and a little earlier Stoll in 1789, began to show us its association with rheumatism, and Begbie in 1847 maintained it was not due to heart caused
by
disease, but with heart disease
genius arrived named Pasteur,
for
nearly forty rheumatism, especially be due to infection
fringe
was
years the idea that children's rheumatism,
of
understanding
we "
humour
has ceased
are
more
flowing
"
rheum
"
or
some
might
over
than
rheumatism":
sometimes think the ancient "
worked at all
being
Yet do not think
world.
also
rheumatism.
Another French and
was
on
the the
indeed I "
peccant
down from the brain of
Some Reflections
Research
on
the rheumatic, and is
brains of all of
by
who
us
Medicine
131
flowing down from the fighting over what is meant
now are
rheumatism and what In
in
are
its
causes.
spite of this pathetic conclusion, I
cannot
help
that all of you who have listened to these stories of the air balloon and of rheumatism must feel
feeling a
has
chord
sympathetic
touched
been
with
our
literature, the Penguin books, price 6d., in
modern
^hich you trace the activities of the detective rival amateur genius discovering the murderer. When
you examinations
naturally moment
as
facts. an
necessity
to
you
a
pass are
looked upon at the You must have facts to achieve
concerned with what
in
success
absolute
an
medicine
studying
are
or
are
and
you must pass fact is the end of its research.
examination,
examinations, but a When I say a to-and-fro
murmur
heard
over
the aortic
is evidence of aortic regurgitation, and prove it to you by a post-mortem examination, the research on that particular point is at an end, for it has become
cartilage
^
fact.
The
"
cram
"
books
on
medicine?mind, I do
decry them?largely consist in a collection of bottled facts, and one great objection to repeated examinations is the danger that your mind is deadened by learning facts, that is you are continually reaching
not
full stops.
Perpetual teaching, exiled,
or
"spoon feeding"
from the earliest moments in the
not assist the research
through
the
spirit.
examination
your view of it to
Say I think you is the
point you
me,
have want.
of
as
it is
wards, does
Now if you blunder and present case a
naturally enough I might missed the point here, this But you
have, nevertheless,
Dr. F. J. Poynton
132 undertaken
a
research, and like everyone beginning
research you may have missed the essential, but you have strengthened your intelligence, not dulled it or kept it stationary. to
research and
There is into
a
a
even
curious idea that
laboratory
to research is
already
may not be. outlined but
detail.
That is
may
or
work of
someone
a
who drifts
superior being.
He
He may carry on some work needing to be studied in more
superior to the confirming some new already made but requiring more but it is not
good work,
someone
in the wards
clinical observation confirmation.
ending
This is often called
"
hack work."
I
don't call it hack
mysterious superior being
or
work, but useful work, though not marvellous work. This, then, is no
because he is in
marvellous than
more
laughs It is
a
laboratory,
his friend the
he is not
clinician he
at.
clearly, then,
most
important that we recognize laboratory research,
that there is clinical research and and
post-mortem evidence
too when that is
needed
keep us steady. There is no place on either side for antagonism. It must be remembered that clinical research may anticipate laboratory research, although the exact explanation of the clinical observation may have to await the laboratory investigator. I knew the great children's physician, Dr. Cheadle, to
very well, and he told me that as a result of his travels in Canada he had seen and learnt much about scurvy
returning to England he found doctors terribly puzzled over a condition in infants brought about by patent foods. No one knew how to He from his treat it or what it really was in nature. in
adults, and that
on
observations and research into the scurvy of adults
Some Reflections at
once
Jt
by
on
Research
realized it to be scurvy in fresh foods.
He insisted that there
was
infancy, a
133
Medicine
in
and he cured
lack of
something
which he called the antiscorbutic element in the patent
foods,
because he had studied adult scurvy and its causation. Now you all recognize that element as
Vitamin C,
but many infants had been saved before you knew this or I knew it, and one of the duties of a
doctor is
to
Vitamin
C.
save
life,
even
if he cannot
give
the
name
The reverse, of course, occurs. I have only to Mention insulin and many other instances will occur to you. I am putting aside for simplicity's sake any question of the financial side of our subject, though I would Remind you that the great investigators have often Worked in very small laboratories, and that a Magnificent laboratory does not always mean good
Work, though it is It
is
useless
a
great
to
lay
asset to
down
good laws
work. for
the
born
He or she stands apart from us, with that curious gift of seeing something that seems new ; that outstanding patience against failure or derision,
investigator.
because
he knows that it is
something
new, and that
concentration on the goal ahead. He may not succeed he may be wrong, but he leaves a track of some kind
0r
Which is of value, and by his mental power trains others who may surpass him in results.
^variably stimulating aiid
obey
their
they
are
Now when the laboratory investigator,
Worker, begins
are
in the boldness of their outlook
of purpose, but own laws.
tenacity
Such minds
to scoff at and deride the
minds which
as a
research
clinician he
Dr. F. J. Poynton
134
I have been a pathologist, a way. bacteriologist, and a clinician in my time, and I have worked shoulder to shoulder with each type, though I is
in
bad
a
became
clinician
a
eventually
I admire all
human side.
because I loved
types,
but when
a
the
vaccine
laboratory undertakes to cure a specialist living case of malignant endocarditis, and after his injections the temperature slowly falls and the patient dies, and in
he does not
a
post-mortem examination
to the
come
;
further, when he is content to say if he had commenced the treatment sooner the patient would have lived, X think
badly
of him.
what the clinician was
the
sign
Why
?
Because he did not know
knows, that the fall in temperature
patient's resistance was exhausted, partial success of a vaccine. If he had
that the
and not of the
autopsy he would have seen the impossibility of his claim, but as it is he returns to his come
the
to
laboratory believing bad way. In this
laboratory
in
a
partial
success, and he is in
a
you see two instances of research, the research which I do not criticize, and the
case
clinical research which led the
physician to recognize from his knowledge of malignant endocarditis and from his knowledge of his patient that the fall of temperature was premonitory to death. The weak point was the ultimate failure in research of the laboratory investigator in not facing the findings of The physician could the post-mortem examination. also have told him that he had the
earliest
moment
endocarditis and had
If, however, at
some
a
of
even
physician
future time
a
seen
vaccines used at
detection then
seen
malignant
them fail.
possibility that might be discovered
denied the
vaccine
of
Some Reflections
on
Research
Medicine
in
135
which would be successful, he would be speaking without the requisite knowledge of the possibilities of
laboratory lines,
research, and would be also moving
because he could not
laboratory
bad
know the future of
research.
Take another care
possibly
on
A
case.
physician
of anaemia which he
a case
has under his
assumes can
be cured
with
massive doses of iron, but the case does not improve. He is persuaded to call in from the laboratory
expert upon examination of the blood, who at once points out that it is a pernicious anaemia. Here the physician has failed in his research mind, and has
an
assumed
that
once
laboratory To
stress mind as
are
from
his
own
experience
to
laboratory research worker could be an erroneous assumption from his
researches.
recapitulate on
knew
that the
something Prove at
he
at this
point.
I have been
laying
the belief that the essentials of the research to be found in
wards,
at the
bedside,
as
well
laboratories; that the various research minds should try to keep in touch with the main object? in
the advancement of medicine?and not become aloof
from
one
ttiind is guided
another; and that the outstanding research one
by
which makes its 'own laws and is not
ours;
and, lastly, that such minds have
a
stimulating
effect upon us by their peculiar quality and power to make us think. You may ask: How can the research mind help lri
every-day work ? It can help from the first. For instance, in reminding you that you are not studying a pneumonia, but a case of pneumonia, a human being suffering from pneumonia. Then you begin to realize the truth, for you find yourself inquiring in your mind,
136
Dr. F. J. Poynton
why
did this
do well and that
case
one
do
badly
You
?
led to research away from the pneumonia into the type of pneumonia, into the influence of age, of alcoholism, of overwork and under-nourishment and are
results, after the necessary experience brought alone by time, in making the competent doctor, the practitioner who becomes It is this habit of mind that
so on.
is sound.
trusted because his
thoroughly
judgement Year after year, unconsciously perhaps, he researching not only into pneumonia, but
has been into how
pneumonia and other illnesses may affect this
or
that
individual. I could
the
type of mind when I was examining. When, for example, I asked some question upon see
treatment, and the case
"
came,
If I had
earlier I should have advised immediate
but I
am
not certain that
The
great." was
answer
the
particular
same
recognized
from the
weak,
a
too
being
old,
had altered
or some
qualified as
cases
and in
some some
In this
There is
no
answer
I
doubt that
curious
point, some unexpected happening
assists the research mind.
over
he had
undertaking of
practice you may laugh
I have
:
complication had
student the rather wearisome
about one's notes
first, but the examinee had
research mind.
noting down each day interesting comment, or
operation,
the risk will not be too
the issue doubtful.
arisen
making recognized the
or
this
condition under consideration
that the human
become too
when
now
seen
mine, but
they
When
your old served their
over
purpose. We must realize that the research mind is to some extent adventurous and takes the risks of adventure,
and to
me
it has
seemed that when
a
particular
Some Reflections
physician
keep lose
asks
on
Research
in
137
Medicine
questions of students that those who
well in the back
row
to avoid
answering
them
thereby.
You may be
do
some
quite sure of this. If you eventually research, so often called original?but so
as you will be surprised to find actually original have to face up to criticism and to cultivate will ?you a placid, I don't say a pacific, mind to carry you along. If the work is important and you believe sound
rarely
you must defend it, but if from studentship feared criticism and making some mistakes have you
certainly
you will not
easily keep
your
equanimity later,
and
you may even turn tail. There is much to be learnt, of course, in laboratory "training just as there is in surgery?much accuracy, and
in
some
instruments, can
cases
knowledge
of
handling
on, before the actual investigation Some minds naturally undertaken.
and
be
much
so
safely enough prefer the wider, more philosophical nature of niedicine, or the practical details of preventive medicine, hut they are not safe from researoh. You
never
know, in whatever branch of the
Profession you are, whether opportunities may not arise which put you into the position of making some useful contribution.
This leads
consideration, the
putting
published form.
art
of
This is also
a
type
me
to another
your work into of research. It is
a
research into the minds of those whom you think ^ill read your work. Do not suppose I am going to
advise you to study my writings for this purpose. I have written three books, numerous lectures and a dreadful number of medical articles, and I was told
recently by
the candid friend and the
gentle
critic that
Dr. F. J. Poynton
138 "
I wrote
I
journalese."
by
am
nature not
easily
moved, and love the humorous side of things, and my retort
an
was
easy
one.
three books
and
published send?reprints of your
It are
"
When you have asked for?I do not mean
was :
lectures
come
and
see me
again
and talk it over."
great pitfalls in writing. One is, to suppose the reader knows the subject as well as you do yourself. There
are
Another to
use a
number of
only a few are necessary. complicated graphs in great reader
who
is
not
long
scientific words when
Another to suppose that numbers can appeal to a
acquainted
with
complicated
diagrams. Another to presume that everyone who may not agree with your new and perhaps debatable conclusions is a fool. Even if I am a fool I do not like to
feel
it, and the enemy bides his time
to
strike
back. A summary at the end of your paper should avoid " the obvious. Such as this (No. 1) : We have shown that rheumatism is
a common
disease."
We all know "
already. Or an ending such as this (No. 2): We have investigated x number of cases for such and such a point, but it will require many more before we can We decide upon the real interpretation." (No. 3): publish these results as a preliminary step." Why publish them if you want many more cases to prove the meaning of your point ? Why not wait and not trouble to inform the medical profession rheumatism I am very suspicious of & is a common disease. preliminary report, because so often one never hears It reminds me of showing a difficult the sequel. clinical case you cannot diagnose and never reporting later the fate of that case. Lastly remember : What that
"
"
Some Reflections
on
written is written."
be surprised if, in your view not
Research One often
in
Medicine
regrets this.
139 Don't
of accuracy, you may find understood, or garbled. Be patient.
spite
There is another
aspect of research,
interesting specialization, and tendency probably in the end complete specialization. It is a clear impossibility to investigate everything
?ne.
This
is
the
to
in medicine, but I do think this, that to realize
that
investigation
when
an
we
we narrow our
we
should
try
take up special lines of outlook on human illness,
and may lose a sense of proportion. We should be on guard lest we become fanatics. There are plenty of instances of able
people
who have found out
a
half-
truth?and it may be a valuable half-truth?and have then surrendered their research mind to fanaticism, ^lore and more is to be explained by this half-truth,
everything is to be explained. Such able niinds may become actually deranged. Doctors who have to teach students are much protected against this, for the student requires varied teaching. Again, those cail listen to other views are much protected. You can quite easily become a fanatic over rheumatism. You can become a fanatic over the bacteriology, the endocrines, the diet, the gold as a drug or as a reward,
Until at last
the local focus, the rheumatic diathesis, bee venom, the climate, the sympathetic system and allergy. How
not
can
you
prevent this danger
?
I think
by
shutting yourself up in the chamber in which your Particular idea is living, but by listening to the words ?f others living in other chambers, perhaps they also inclined to be fanatics. You say to me, "Malfunction ?f the endocrines explains all rheumatism." And I ask, " Does a child aged three with Still's disease or
140
Dr. F. J. Poynton rheumatoid arthritis suffer from endocrine
juvenile
"
I say to What is your proof of that ? All rheumatism is due to an infection." You
malfunction ? "
you,
"
"
What is rheumatism ? Even as Pilate say to me, " " " I What is truth ? If I am honest I say, said, "
And you reply, How, then, do " you know all rheumatism is due to an infection ? Signs of fanaticism appear sometimes early in a don't
really
know."
student's career, and I don't like to see it, because it grows with age. Fanatics, it is true, have done wonders in
great
human disease it is
balanced, yet has that is the
results,
complicated study of frequently the mind that is
causes, but I think in the more
some
great truth
often the
to make known?
that obtains far-reaching because it knows that this truth cannot be more
one
forced upon unwilling ears, but must wait for results which bring conviction. Lister held firmly to the great
principle
of
and
antisepsis,
he
won
his
continuous efforts to show that the results his
faith,
not
as a
fanatic,
but
as a man
who
way
by
justified saw
that
the truth must the
justify itself and not be thrust against unwilling, thereby increasing resistance to its
acceptance. One of the as a
result is of any use. We must admit that deal of research seems to be lost, but we have
to whether
great
great difficulties in research is the doubt
a
also to admit that
we
never
know when something
apparently lost and useless may not be found to be of value. Many a man has suffered the fate during life apparently useless. Later, when he is dead, some change in thought has occurred and the true value of his work is suddenly discovered. I do not think anyone can guard against this. It is the fate that of
finding
all his work
Some
Reflections
comes to
only
the
to
are
get
and interest of the
pleasure the
and
not realize how
long
give short time aids
a
time it
subject you wish example, requires
grasp of the Rheumatism, for a
investigate. ^ast two years' study before you can difficulties and the problems. Yet there is to
joy of
grimmer
adversary.
Some of you may to
the
individual
the
combating takes
141
Medicine
in
pioneers in all departments of life, and the
consolations
work
Research
on
to research
such
at
the
grasp a
to
tendency
subject beginner. It seems to me that the time is up before he has had a chance to know the outlines of the
to
on
a
a
subject, result,
and and
*niperfect spent
yet he is obliged, perhaps,
produces through
&!ves it up.
of his life A
upon research, It is
produce
real fault
some
a
very
Then, maybe, he considers he has
one.
enough
no
to
good
as
you
on
this
deal of can
investigation money is easily
guess.
and he wasted
It is inevitable.
interesting point for the philosopher to ground which has been already explored and supposed to have yielded all its usefulness should be again explored by a beginner. If it is very lrnportant ground I think yes, for though you may arrive at the same results, you may see things from a different angle to the forerunner, and as a result side bracks be started from the main track. a
very
consider whether
Some things
and
are
so
well
established,
so
certain,
so
thoroughly recognized that continual repetition helpful. They have become facts, and most 1Inportant ones, but not requiring continual repetition,
*s not
Unless there
are
some
side tracks to be learnt from
them. There are limits there is so much that is Tr
0L-
to
repetition, especially
new
when
to discover. L
Liv.
No. 204.
142
are
Some Reflections
on
Research
Medicine
in
We cannot escape from the fact that some minds not meant for research in laboratories, though the
individuals may believe they have this flair. " vision get into a groove and lose that
Soon "
they
which is
required, and as you will know when you get to middle age, though some outstanding minds do not weaken in vision, most, like the singer, find themselves driven to sing the old songs that were once attractive but are not
new.
The mind of
a
child does not remain with
most of us, but it is the mind of
original, because unfettered by clearly the essential.
a
child that is
custom it
sees
so
very
