Whether ban on appearance of outside lawyer in court infringes his right to practice
PRACTICE OUTSIDE THE SERVICE
1
545 the practice will not be eliminated completely from some of the more remote areas. It is difficult to break the vicious circle. The operation is entirely the affair of the women. No man-not even a qualified doctor-has any part in the ceremonies at all. The husband, no matter what his feelings, is often powerless to stop the practice. By doing so, or by trying to do so, he embitters his relations with the female side of both families. We would further point out that the Sudan now has its own elected Legislative Assembly, whose members are conscious of this problem. They are best qualified to find the most acceptable solution, and can be trusted to do so. Continued publicity, often ill-informed, might well be interpreted by the Sudanese as interference in their own affairs, and undo much good that has already been done. c/o London School of Hygiene and Tropical Medicine, London, W.C.1. A. O. ABU SHAMMA M. A. ALI I. ANIS J. F. E. BLOSS H. 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 the I must apologise to you, to Dr. Graham, and to all within the service who find, as she does, that they have time to do unhurried work. That some doctors in the 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 his list, so I cannot give first-hand proofs ; but from what has been told me by patients, by hospital residents, and by good and conscientious practitioners in the service, I cannot doubt that many doctors find they cannot give, and many patients find they cannot get, anything like the time and attention the nature of the case demands. I should be astonished if it were otherwise, and unless I am really quite wrong in my facts I think they should be freely admitted, and indeed proclaimed, or else the defects will never be amended. If all is well with the service I and my like shall, of course, soon sink ; no tears need be shed for us and perhaps no ink should be wasted 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 Control Medical Advisory Committee against adverse criticisln.1 It may interest your readers who have had no experience of this body to know of the method by which-so far as pulmonary tuberculosis is concerned-it decides whether 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 the latest 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 charge of the case, which may be considered of the first importance since he knows the patient from long acquaintance and from every 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 whole investigation 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 clinical attributes it reaches-from the case-history and the shadows in an X-ray film-a decision with far-reaching effects on the sufferer. In private practice not one member of the committee would accept this evidence as sufficient to discharge his duty to the patient. One might as well expect a court of law to decide innocence or guilt without hearing both sides, and without a jury. Folkestone. B. G. EDELSTON Chest Physician, South-East. Metropolitan Regional Hospital Board. 1. See p. 540. LIVER EXTRACTS SrR,-Dr. Wilkinson, in his letter of Feb. 5 and in his Oliver-Sharpey lectures printed in your issues of Feb. 12, 19, and 26, has suggested that livers classified by the Ministry of Food as suitable for pharmaceutical purposes, are in fact diseased, lacking in anti-anaemic potency, and unsuitable for the manufacture of liver extracts. Major Guy Lloyd raised the question in Parliament on Feb. 24, when Mr. Aneurin Bevan stated that the extract, though it might not be effective, was quite safe. 1 If it is true that the M.O.F. livers are deficient in anti-anaemic principle, it is a very serious matter and evidence should be produced in support of this contention. Although there is no statistically reliable evidence, there appears to exist a strong clinical impression that the minimum therapeutic doses of liver extract required at the present time are larger than those necessary before the war. If this is true, the fault must lie either with the patient or with the liver extract. If it is due to the extract, the fault must be either with the process or with the starting material. At one time during the war the M.O.F. liver allocation was satisfied partly by home-killed and partly by imported liver. It was therefore possible to compare these two types of liver side by side and to compare liver extracts made from them. There were certain differences between the imported and home-killed liver. The weight of water-soluble extractives from each was of the same order, but the amount of solid matter which accumulated in the active fraction, when a certain purification process was adopted, was higher in the case of home-killed liver. This is probably explained by a rather greater degree of autolysis in home-slaughtered material than in liver packed by one of the highly specialised stock- yards in meat-exporting countries. The values of six members of the vitamin-B complex were almost identical in each type of liver. The amount of folic acid was much higher in imported liver than in home-killed. This I reported to the 1948 Pharma- ceutical Conference, offering the suggestion that it could be explained 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 liver was used for its preparation. In addition, graphs constructed from red blood-cell counts obtained during the clinical trials of 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 microbiological assay of each type of liver. This is under investigation in these laboratories ; but subject to confirmation we have found 2 ptg. of vitamin B12 per g. of wet liver in the portion which on paper-chromatography migrates considerably less than riboflavin. The examination was performed after digesting liver with papain and without subjecting it to any fractionation 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 in active material. Dr. Wilkinson also states of certain highly purified liver preparations that it is clear that they are either " not being tested adequately before issue ... or only some batches are being tested, or some accessory factor has been removed, or the preparation does not remain active after issue." Most reputable British m-anufac- turers claim to test every batch. Has Dr. Wilkinson therefore taken the matter up with the manufacturers of the particular batches implicated, and preferably also with the haematologist who is supposed to have tested these batches ? P It is perhaps premature to dogmatise, but evidence appears to be accumulating that vitamin B12 will, so far as pernicious anaemia is concerned, entirely duplicate the effects of a parenteral liver extract ; the accessory-factor hypothesis, although possible in certain cases, does not appear to stand on very firm foundation. If it is a fact that more liver is needed now than before the war, the fault may be with the patient, since for 10 years the general level of diet, especially in meat products rich in animal-protein factor, has been considerably less than that in the pre-war era. 1. See Lancet, March 5, p. 420.
Transcript of PRACTICE OUTSIDE THE SERVICE
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.
