545

the practice will not be eliminated completely from someof the more remote areas. It is difficult to break thevicious circle. The operation is entirely the affair of thewomen. No man-not even a qualified doctor-hasany part in the ceremonies at all. The husband, nomatter what his feelings, is often powerless to stop thepractice. By doing so, or by trying to do so, heembitters his relations with the female side of bothfamilies.We would further point out that the Sudan now has

its own elected Legislative Assembly, whose membersare conscious of this problem. They are best qualifiedto find the most acceptable solution, and can be trustedto do so. Continued publicity, often ill-informed, mightwell be interpreted by the Sudanese as interference intheir own affairs, and undo much good that has alreadybeen done.

c/o London School of Hygieneand Tropical Medicine,

London, W.C.1.

A. O. ABU SHAMMAM. A. ALII. ANISJ. F. E. BLOSSH. EL HAKIM.

PRACTICE OUTSIDE THE SERVICE

SiR,-If, under the little cap of darkness your peri-patetics are allowed to wear, I have indeed maligned theI must apologise to you, to Dr. Graham, and toall within the service who find, as she does, that theyhave time to do unhurried work. That some doctors inthe service can do this is, of course, not in dispute ;that many or most at present cannot was, I supposed,generally admitted. I have not tried being a " locum "for, or a patient of, a doctor with 2500 or 3000 on hislist, so I cannot give first-hand proofs ; but from what hasbeen told me by patients, by hospital residents, and bygood and conscientious practitioners in the service, Icannot doubt that many doctors find they cannot give,and many patients find they cannot get, anything likethe time and attention the nature of the case demands.I should be astonished if it were otherwise, and unlessI am really quite wrong in my facts I think they shouldbe freely admitted, and indeed proclaimed, or else thedefects will never be amended. If all is well with theservice I and my like shall, of course, soon sink ; no

tears need be shed for us and perhaps no ink should bewasted on us in the meantime.

PERIPATETIC OUTSIDER.

MEDICAL TREATMENT ABROAD

SiR,—I hear that in the House of Commons Mr.Douglas Jay has been defending the Exchange ControlMedical Advisory Committee against adverse criticisln.1It may interest your readers who have had no experienceof this body to know of the method by which-so faras pulmonary tuberculosis is concerned-it decideswhether or not to grant currency permits.The doctor (usually the chest physician of the area in which

the applicant lives) sends the medical case-history and thelatest X-ray film of the patient to the secretary of the com-mittee ; and upon this slender evidence the case for or

against is judged : the opinion of the physician in chargeof the case, which may be considered of the first importancesince he knows the patient from long acquaintance and fromevery aspect, appears to carry no weight and to be ignored.

It is an axiom of medical practice, especially applicable’to pulmonary tuberculosis, that no one part of the wholeinvestigation of a case can be exalted above the rest,and that the lesser cannot be made to include the greater.Yet that is what the committee does. Without know-ledge*of the applicant’s mental, physical, and clinicalattributes it reaches-from the case-history and theshadows in an X-ray film-a decision with far-reachingeffects on the sufferer. In private practice not one memberof the committee would accept this evidence as sufficientto discharge his duty to the patient. One might as wellexpect a court of law to decide innocence or guilt withouthearing both sides, and without a jury.

Folkestone.

B. G. EDELSTONChest Physician, South-East.

Metropolitan Regional Hospital Board.

1. See p. 540.

LIVER EXTRACTS

SrR,-Dr. Wilkinson, in his letter of Feb. 5 and in hisOliver-Sharpey lectures printed in your issues of Feb. 12,19, and 26, has suggested that livers classified by theMinistry of Food as suitable for pharmaceutical purposes,are in fact diseased, lacking in anti-anaemic potency, andunsuitable for the manufacture of liver extracts. MajorGuy Lloyd raised the question in Parliament on Feb. 24,when Mr. Aneurin Bevan stated that the extract, thoughit might not be effective, was quite safe. 1

If it is true that the M.O.F. livers are deficient inanti-anaemic principle, it is a very serious matter andevidence should be produced in support of this contention.Although there is no statistically reliable evidence, thereappears to exist a strong clinical impression that theminimum therapeutic doses of liver extract required atthe present time are larger than those necessary beforethe war. If this is true, the fault must lie either with thepatient or with the liver extract. If it is due to theextract, the fault must be either with the process or withthe starting material.At one time during the war the M.O.F. liver allocation

was satisfied partly by home-killed and partly byimported liver. It was therefore possible to comparethese two types of liver side by side and to compareliver extracts made from them.

There were certain differences between the imported andhome-killed liver. The weight of water-soluble extractivesfrom each was of the same order, but the amount of solidmatter which accumulated in the active fraction, when acertain purification process was adopted, was higher in thecase of home-killed liver. This is probably explained by arather greater degree of autolysis in home-slaughtered materialthan in liver packed by one of the highly specialised stock-yards in meat-exporting countries. The values of six membersof the vitamin-B complex were almost identical in each typeof liver. The amount of folic acid was much higher in importedliver than in home-killed. This I reported to the 1948 Pharma-ceutical Conference, offering the suggestion that it could beexplained by the food on the open range in the Argentine,which differed from the concentrate feeding in England.As regards therapeutic potency, dried proteolysed liver was

found to be equally effective no matter which type of liverwas used for its preparation. In addition, graphs constructedfrom red blood-cell counts obtained during the clinical trialsof parenteral extracts made from (a) imported liver and(b) liver from home-killed animals, intermingled indiscrimin-ately when both series were drawn on the same paper.

Further evidence could be obtained by the microbiologicalassay of each type of liver. This is under investigation inthese laboratories ; but subject to confirmation we havefound 2 ptg. of vitamin B12 per g. of wet liver in the portionwhich on paper-chromatography migrates considerably lessthan riboflavin. The examination was performed after

digesting liver with papain and without subjecting it to anyfractionation procedure other than paper-chromatography.The above evidence would appear to suggest that the

livers issued by the M.O.F. are of satisfactory content inactive material.

Dr. Wilkinson also states of certain highly purifiedliver preparations that it is clear that they are either" not being tested adequately before issue ... or onlysome batches are being tested, or some accessory factorhas been removed, or the preparation does not remainactive after issue." Most reputable British m-anufac-turers claim to test every batch. Has Dr. Wilkinsontherefore taken the matter up with the manufacturersof the particular batches implicated, and preferably alsowith the haematologist who is supposed to have testedthese batches ? P It is perhaps premature to dogmatise,but evidence appears to be accumulating that vitamin B12will, so far as pernicious anaemia is concerned, entirelyduplicate the effects of a parenteral liver extract ; the

accessory-factor hypothesis, although possible in certaincases, does not appear to stand on very firm foundation.If it is a fact that more liver is needed now than beforethe war, the fault may be with the patient, since for 10years the general level of diet, especially in meat productsrich in animal-protein factor, has been considerably lessthan that in the pre-war era.

1. See Lancet, March 5, p. 420.