544

raise the upper limit of his normal from 1500 to 1700.One is not greatly impressed by Dr. Bene’s assumptionthat in those patients of Dr. Martin and Miss Lovell,whose B.M.R. showed the widest diversion from theR.P. index, the B.M.R.s must have been incorrectlymeasured or the disease incorrectly diagnosed.But in any case, Sir, does all this matter very much ?

Surely the diagnosis of thyrotoxicosis remains a question- of clinical acumen. The proportion of cases in which aB.M.R. is helpful in the diagnosis is comparatively small.A physician who is helped by any method which at itsbest is approximately correct in only two-thirds of hispatients, had better leave the diagnosis of thyrotoxicosisalone.

Thyroid Clinic, New End Hospital,London, N.W.3.

RAYMOND GREENE.

LYMPHOCYTES AND INTRAVASCULARHÆMOLYSIS

SiR,—I agree with Mr. Catton (March 19) that thecells seen in peripheral blood-smears from my patientwith Hodgkin’s disease accompanied by haemolyticanaemia are lymphocytes in process of dissolution ; butthat they are not dead cells is suggested by the normalappearance and staining reactions of their nuclei. Similarcytoplasmic protrusions are found in considerably lessthan 0-5% of the,lymphocytes seen in smears made fromnormal individuals, and it is interesting that Mr. Cattonhas seen them in the lymphocytes of fish, in which theymay occur in larger numbers than in the human subject ;there may be species variations in the normal percentageof such lymphocytes.

I know of no previous description of these cells in thehuman subject, healthy or otherwise, and their presencein this case in greatly increased numbers seems to meconsistent with the view that they are related to theintense haemolysis observed. I am not sure that anincrease in the percentage of these cells above normallimits is properly described as an

" artefact," but furtherwork including, as Mr. Catton suggests, the use of thewarm-stage technique is needed for the proper evaluationof the significance of these observations.

South London Blood Supply Depot,Sutton, Surrey.

R. H. TRINICK.

NATIONAL FORMULARY

Sm,-The defence of the National Formulary presentedby some of the eminent members of the committee inyour issue of March 12 is hardly necessary in viewof this volume’s over-all value.- The truth wouldappear to be that one cannot be so dogmatic in aformulary as in a textbook of medical treatment reflectingthe author’s personal views.

I was sorry, however, to see omitted from the formularya historical note referring to the many previous " panel "formularies and the effort which was made to embodythe best in successive editions of the National Formulary.No doubt many of the formulas included in the presentproduction arose originally from these sources : indeed-although I am open to correction—the formula ofWhitfield’s ointment at present in the N.F. is a modifiedformula suggested by my late father.

Secondly I feel that the policy regarding omission ofdiamorphine preparations is wrong. I believe there isa modern tendency to disregard the precise constitutionof the vehicle, which is now expected to provide only asuitable way of presenting the active ingredients. Doesthis mean that the various preparations of heroinincluded in the B.P.C. should not be prescribed as such,the dosage of heroin being determined by altering thetotal dosage suitably ?The drawback about the present National Formulary

is that the committee appear to have striven to satisfyeverybody, instead of concentrating primarily on thegeneral practitioners’ requirements. Despite the reas-surance that a prescriber is not bound to the formulary,in general practice it will no doubt become, as did itspredecessors, the doctor’s mainstay. It includes manyB.P.C. preparations, though still lacking many of thepreparations therein described, such as the syrups.It also omits the syr. cocillanae co. of the Drug Tariff,although it brings in elixir caffein. iod.

Reduction of the books of reference for prescribersshould be one of the ultimate aims of the committee:and when these are stabilised, such things as appliancesmight be reincluded although in a more comprehensiveway than in previous formularies. Despite the com-mittee’s efforts such perennial troublesome formulas asmist. acid. acetylsalicyl. reappear. My late father wasso disgusted with this preparation that he gave aspirintablets with the appropriate instructions instead, andno doubt many would agree.On reflection, studying the old North of England

Medical Formulary, it would appear that formulationof many of the mixtures has not improved with time,and the reintroduction of some of these together withcolouring agents not prone to the disadvantages ofliq. azorub. might be of benefit. Despite the passage ofyears some of these are still prescribed.Some of the directions given by the committee cannot

be quite clearly defended. How is a doctor to prescribeordinary syrup of figs B.P.C. when the committeecategorically state that the compound preparation shallbe dispensed ? I appreciate that this is not much used,and is infrequently stocked by pharmacists; butnevertheless this is no criterion to veto its prescribing.

This is minor criticism of an outstanding effort.Finally, the value of this book would be greatly enhancedby cutting the edges of the paper according to

" mixtures,"&c., and by the use of tinted paper (e.g., for thechildren’s section), to provide even quicker referencethan with the comprehensive index.

Newcastle-on-Tyne. A. FORSTER.

FEMALE CIRCUMCISION IN THE SUDAN

SiR,-In your issue of March 12, Sir Basil Neven-Spence, M.p., discussed once more the question of femalecircumcision in the Sudan which he recently raised in theHouse of Commons. He has met Sudanese doctors andothers, and an adequate reply was given to him on bothoccasions. It is difficult to see what is the purpose ofhis letter to your journal.The more severe form of female circumcision, the

pharaonic method, is now illegal in the Sudan. It isonly natural that some time must elapse before thispractice is totally abolished, especially in the more

remote areas of that vast country. Rightly or wronglythe practice still.has a deep-rooted significance to manyof the northern Sudanese. It would create the greatestill-feeling if action were taken to examine every girlto investigate whether or not the more severe formof circumcision was still being practised. One canremember how Regulation 33B created ill-feeling in thiscountry, and was considered by some incompatible withthe freedom of the individual. Without such dictatorialmethods (which we think it wrong to enforce) accuratestatistics are impossible. The facts remain that theworst form of female circumcision is now illegal, that theSudanese themselves have formed a society to abolishthis practice, and that they themselves (knowing thepeople) state that it is declining rapidly, especially amongthe more educated classes. What those educatedcitizens practise today will be the practice of othersin time.

It has been publicly stated that the practice is spreadingto the southern areas where any form of female circum-cision was not previously known. One of us (J. F. E. B.)has had nearly ten years’ service all over the southernSudan, another (I. A.) has had six years’ service in theNuba Mountains. The remainder (all qualified medicalmen) have had from one to six years’ service in thesouthern Sudan. We can state definitely that we havenever met any case where female circumcision has beenperformed on one of the indigenous inhabitants of thoseareas. We feel that the statements made by some whohave never served in those areas are untrue, and veryunfair. Anyone knowing those areas and the peopleswould realise that it was unlikely that female circum-cision would ever be tolerated. Even if a few exceptionaland isolated cases did occur, it is extremely improbablethat the practice would spread so as to become a

regular custom.The difficulties are those of education, especially

female education. Until all have e a good primaryeducation, and more have an intermediate education,

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.