AS OTHERS SEE US.

510 We ask the doctor to demand British produce and, furthermore, convince himself that what is stated to be British is British, and by so doing enable us to give employment to more and yet more British workmen and to compete with foreign enterprise on the unequal above mentioned. We are. Sir. vours faithfullv. JOHN BELL AND CROYDEN, LTD., Wigmore-street, W.; JOHN BELL, HILLS, AND LUCAS, LTD., Tower Bridgeroad, S.E.; BRAND and Co., LTD., South Lambeth-

footing

road, S.E. ; BLEASDALE, LTD., York; J. L. BULLOCK Co., Hanover-street, W.; BURGOYNE, BURBIDGES J. R. CAVE, LTD., AND Co., LTD., East Ham; Southport ; COOPER LABORATORIES, Watford ; CURTIS AND Co., Baker-street, W.; CUXSON, GERRARD, AND Co., LTD., Oldbury, Birmingham; DUNCAN, FLOCKHART AND Co., Edinburgh and London; GALEN GALE AND Co., Bouverie-street, E.C. ; MANUFACTURING Co., LTD., New Cross-road, S.E.; GOODALL, BACKHOUSE AND Co., LEEDS ; HANDFORD AND DAWSON, Harrogate ; HARRINGTON BROS., LTD., City-road, E.C.; HODGKINSON, PRESTONS, AND KING, LTD., Bishopsgate, E.C.; JEYES’ SANITARY COMPOUNDS Co., Cannon-street, E.C.; THOS. KERFOOT AND Co., Bardsley Vale, Lancs.; H. AND T. KIRBY AND Co., LTD., Willesden; HOWARD LLOYD AND Co., LTD., Leicester ; LOFTHOUSE AND SALTMER, Hull ; W. MARTINDALE, London ; MOTTERSHEAD AND Co., Manchester; G. T. W. NEWSHOLME, LTD., Sheffield ; OPPENHEIMER, SON, AND Co., LTD., Queen Victoria-street, E.C.; PAINE AND Co., St. Neots, Hunts ; PEAT PRODUCTS, LTD., Queenhithe, Upper Thames-street, E.C. ; PECK AND SON, Cambridge; POTTER AND CLARKE, LTD., Artillery-lane, E.; PRIDEAUX, LTD., Motcombe, Dorset ; RAIMES AND Co., York ; RAIMES, CLARK, AND Co., LTD., Leith ; F. ROGERS, Oxford-street, W.; RICHARDSON AND Co., Blackpool ; JOHN RICHARDSON AND Co., LTD., Leicester; F. M. RIMMINGTON AND SONS, Bradford; SQUIRE AND SONS, LTD., Oxford-street, W.; STANDARD TABLET AND PILL Co., LTD., Hove ; H. E. STEVENSON AND Co., LTD., London, S.E.; SYMES AND Co., LTD., Liverpool ; TYPKE AND KING, LTD., Mitcham ; THOS. TYRER AND Co., LTD., Stratford; WHIFFEN AND SONS, LTD., Battersea; WRIGHT, AND

LAYMAN,

AND

UMNEY, LTD.. Southwark-street, S.E.

THE SEPARATION OF PRESCRIBING AND DISPENSING. To the Editor

OJ THE l.JANcmT. to letter of Mr. J. 0. Braithwaite the SIR,—In reply in your issue of Feb. 26th, the Ministry of Health Committee of the Pharmaceutical Society admits, in its report which appeared in the Pharmaceutical Journal of May 15th, 1920, that the only statutory qualification in the dispensing of medicines is that held by the apothecary’s assistant, also that the statutory qualification of the pharmacist for the dispensing of poisons applies only to open shops, and only to scheduled poisons. A hospital or institution cannot be held to be If there is to be any separation of an open shop. prescribing and dispensing the apothecary’s assistant can justly claim priority to dispensing in any places other than open shops. I should like to point out that in the orders governing the appointment of dispensers to many public hospitals, institutions, &c., the apothecary’s assistant is equally eligible with the pharmacist, and in order of precedence appears before the pharmacist, and further, as a matter of fact he discharges his duties in these places to the entire satisfaction of those concerned. Mr. Braithwaite seems to have overlooked the fact that the business of a chemist and druggist has many things in common with the herbalist and grocer, and if such classification is necessary the pharmacist certainly has the prior claim.-I am, Sir, yours faithfully, H. C. RICHARDS, Hon. Secretary, Association of Certificated Dispensers. Hathaway-road, Croydon, Feb. 27th, 1921.

RACIAL TUBERCULOSIS SUSCEPTIBILITY. To the Editor

of

THE LANCET.

30th,

SIR,—In an annotation in THE LANCET of Nov. 1920, figures are quoted from a paper by Professor S. Lyle Cummins, contrasting the rates for tuberculosis in the British Army with the much higher rate which prevailed amongst the men of the South African Labour Corps, and using these as an illustration of. the

susceptibility of primitive races to a new disease and This use of their inability to withstand its attack. the figures is not justifiable in regard to South African natives at all events. In a paper written in 1911, a precis of which appeared in THE LANCET of May llth, 1912,1 gave evidence to show that the great susceptibility of South African natives to pneumonia and tuberculosis was due to the great prevalence of a syphilitic taint in all native tribes in South Africa, and that they took these diseases in a virulent form. In a subsequent paper (THE LANCET, April llth, 1914) it was shown that a similar susceptibility, in a somewhat less degree, applied to the white population also. The ancient and often-quoted example of the heavy mortality resulting in a " virgin soil " from such a disease as measles is easily understood by anyone who knows the habits of natives when suffering from any febrile disease without putting the onus therefor on the "virgin soil," as Professor Cummins seems to do. T

n-m

Sir.

ours

faithfully.

B. G. BROCK.

AS OTHERS SEE US. To the Editor of THE LANCET. SIR,-The letter with this title by Dr. Harry Roberts in THE LANCET of Feb. 26th has touched me in a marked degree. The author of " Chronicle of a Cornish Garden," a fellow-student of mine some 30 years ago, concentrated his early energies in the congenial air of a wide and wild part of England, only to remove later to the drab and depressing atmosphere of an East-end district. No wonder he unconsciously contrasts, in his mind, the almost undisguised worship of a simple and kindly country-folk with the more shrewd and critical audience of the town wage-earner. Perchance if he had practised first in the sordid surroundings of some vast city and then transferred his sphere of action to the free and open country his opinions might have been reversed, and he might even have thought the status of the general practitioner had risen rather than descended. But there is great truth in his letter. The political reformer who dreams wonderful visions of an ideal organisation for both the public and the practitioner is usually just the man who has never had any personal experience of private practice. How many general practitioners, I would ask, represent our profession in Parliament? As is usual among this type of man, in his overflowing enthusiasm and concentration he does everything of which he can possibly think but " the one thing needful." The machinery is all most perfectly made, of the finest metal, intricate, beautiful and wonderful, but, alas, those little drops of oil, that are so essential for it to run smoothly and wisely, have been forgotten, and sooner or later it is doomed to be placed on the scrap-iron heap. The vital factor in the life of medical practice is the relationship between the doctor and his patient. You may organise veterinary surveillance for a flock of sheep or goats and they cannot demur. Human beings are different. They can and will demur. The panel kills or stifles that fine professional relationship which every self-respecting medical practitioner unconsciously seeks. The patient, instead of being an individual, becomes merely an integer. The democratic Briton, whoever he may be, will not tolerate this. He has to put up with it for a time, as there is nothing else to fall back upon, but eventually, I feel convinced, he will resist it to the uttermost. I agree with Dr. Roberts that by far the vast number of practitioners are keenly alive to the Hippocratic oath, and by far the majority, under particularly adverse circumstances and often against tremendous odds, will maintain and dominate an almost intolerable position-, rather than sink to the level of the mean and, may be, squalid surroundings in which they may be placed. Although not on the panel, 20 years ago I tasted the difficulties and position of a country " club-doctor." A certain number of club members take up an attitude that because you are a club-doctor you are unable or unwilling to do justice to them on account of the small fees paid. Their prejudice leads them to think they are not receiving the best attention and, in the case of a protracted illness they will sometimes call in another doctor who they imagine may render them greater

511

paid for their services by agree with Cannon and Washburn’s demonstration of cases, is most dis- the association of hunger-pains with gastric contraction? heartening for the club-doctor who is giving his best In this case the capsule is relieved of tension during the attention under, perhaps, difficult and adverse circum- pain not stretched. The tension here is in the con’stances. What is he to do P He is in the grip of a tracting muscle. From clinical evidence it may be relentless system over which he has no power to cope. asserted with confldence that pain during an attack, .And yet there are others. One, in particular, I whether of angina pectoris, acute appeudicitis, nephritic remember, who after a long illness, from which he or biliary colic, or any other visceral agony is deep and slowly recovered, told me: I shall always respect you, referred by the patient, as well as determinable by the Sir, for what you have done." This, from Dr. Roberts’s physician, to be subparietal. The surface aftermath ’View-point, was a success, though from a materialistic but proves that the circumstances which induce visceral pain reveal the existence of paths in the autonomic standpoint, no doubt, was a failure. In practices such as Dr. Roberts appears to have it nervous system afferent to centres, spinal and cerebral, is a constant and continuous " casting of one’s bread which are usually denied to exist except in very limited upon the waters," but I do believe if we are faithful to numbers. That the visceral nerves are mixed nerves the highest ideals of our profession, we see it back may, however, be shown anatomically. " More than 20 years ago, when delivering the Morison ,again, even though it may be after many days." One lectures in Edinburgh, I showed that " the nerves can only have unceasing admiration for those of our )profession who are fighting to keep alive their spirit- which innervate the pia mater are anatomically similar ;instincts among an uncongenital society and in im- to those which follow, twist round and end on vessels, possible surroundings. Are they not the very salt of and may occasionally be actually seen to take their .our profession and are not these the men that have departure from the nerve on the vessel." It will be assistance, ’"

as

they

will be

This, in many

piece-work."

"

tgiven to our profession in the past the splendid name it admitted that if the vessel be a motor organ the !has won and will, we believe, carry it on unblemished pia mater certainly is not, and that its innervation therefore belongs to the sensory group, however Ao the end of all time ?-I am, Sir, yours faithfully, modifled from the somatic type of the same series. I T. WILSON PARRY. REFERRED PAIN. To the Editor of THE LANCET. SIR,—The time ’was ripe for the leading article on referred pain which appeared in your issue of Jan. 22nd, as is shown by the interest it has evoked. The role of

nerveless automatism in visceral action had been and if a few actors still reluctantly withdraw from that deserted stage and with a silence with which positions once held are abandoned, the curtain is descending and the footlights on that play are growing dim. But all the bustle of an entertaining piece still animates the discussion of the parietal expression of visceral pain. The interest, moreover, in this matter is not only professional, for a long-suffering public, rendered ’valetudinarian, is regaled with this mystery even by the lay press, the Times being most obtrusive in its adulatory appreciation of the parietal interpretation of visceral pain. In due course, however, and with a like conclusion, the curtain will descend on this piece also, for the anatomical fates have decreed it, and they are, on the whole, more reliable prophets than either physiological or clinical vaticinators, although of the latter the clinical may, perhaps, be regarded as the a

iplayed out,

more

trustworthy.

The conclusion reached in your article is that viscera are capable of being the site to which pain is referred under certain circumstances, notwithstanding the wellknown peculiarities of their sensibility. You, therefore, subscribe in this matter, and I think with more justice than is often the case, to the truth of the saying, Securus judicat orbis terrarum. That is, that the " man in the street " with nephritic colic or angina pectoris is aware that he is not suffering from a dermic or hypodermic neurosis, but from a deeper visceral pain. As you remarked in an editorial note on the letter of one of your correspondents (Feb. 6th), this chief point has been ignored by most of your correspondents, who appear to be more occupied with the existence and diagnostic value of the parietal and segmental tenderness which is, at times, the aftermath of an orginally

- deeper suffering. The exception to these is your last correspondent, Sir Clifford Allbutt (Feb. 26th), who bases his views on the embryology and innervation of the serous surfaces " " or " inpacked skin " which forms the capsule of the viscera ; hence, he demurs to Dr. A. F. Hurst’s conclusion, that the viscera are themselves sensitive, given an " adequate stimulus." To accept Sir Clifford Allbutt’s view would be to agree that, unless the investment of viscera be affected, there can be no visceral pain and that all intrascapular visceral innervation is motor in character or function. Even the acutely painful thrombus in a coronary artery hurts, according to him, because of a stretching of the pericardium, which jhe regards as ensuant. How does this conclusion

may remark, in parenthesis, that the intracranial vessels were at that time regarded by physiologists as nerveless and muscular automata. They played, indeed, a leading part in the drama now withdrawn, to which I have already referred. I have also shown that the innervation of the coronary artery is submuscular as well as perimuscular-intravascular as well as extravascular-and that the mode of termination of visceral nerves, whether capsular or intracapsular, is the same.2 My anatomical and clinical experience, therefore, has strengthened me in the position I have long maintained and published, on what have appeared to me to be sufficient grounds-namely, that the site of visceral pain may be not only capsular or peri-organic but also intracapsular and organic. With this view the leading article already referred to seems to be in agreement, although it does not appear to show acquaintance with my work.-I am, Sir, yours faithfully, ALEXANDER BLACKHALL-MORISON.

JOHN HOWARD MCFADDEN. To the Editor of THE LANCET. SIR,-A tribute is due to the memory of John Howard McFadden, who died at Philadelphia on Feb. 16th,

aged 70. He was an unostentatious philanthropist who helped to make progress. Although he was attacking a problem which he could scarcely hope to solve, he cheerfully started and entirely supported for six years a cancer research organisation at the Lister Institute of Preventive Medicine in London. He gave carte blanche, and later on extended the investigations to other branches of medical research-for example, sending expeditions to investigate pellagra in the United States. The researches made in association with the Home Office into the cause of industrial cancer at briquette works are to the credit of Mr. McFadden, who received the thanks of the Secretary of State for what he called his " spade-work," but he never courted publicity. He was a remarkable personality. Equally known in the great cities of Europe and America, he was a sort of "Mr. Potter of Texas," with the sombrero replaced by a silk hat and A cotton magnate, he the revolver by kindness. enjoyed to act the part of an American millionaire. He was a daring speculator, being usually " bullish " when others were " bears," and on one occasion at least he averted a panic in the Cotton Exchange in New York by his sheer force of personality. He was a judge of pictures, and collected a fine gallery of eighteenth-century English art. By medical men he will be remembered for, among his many activities, his practical interest in medical research. I am, Sir, yours faithfully, .

M. C. ROSS.

1 Amer. Jour. of Phys., vol. xxix., p. 441. 2 The Nervous System and Visceral Disease, Edinburgh, 1899.