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We ask the doctor to demand British produce and,furthermore, convince himself that what is stated tobe British is British, and by so doing enable us to giveemployment to more and yet more British workmenand to compete with foreign enterprise on the unequalfooting above mentioned.

We are. Sir. vours faithfullv.JOHN BELL AND CROYDEN, LTD., Wigmore-street, W.; JOHN BELL, HILLS, AND LUCAS, LTD., Tower Bridge-road, S.E.; BRAND and Co., LTD., South Lambeth-road, S.E. ; BLEASDALE, LTD., York; J. L. BULLOCKAND Co., Hanover-street, W.; BURGOYNE, BURBIDGESAND Co., LTD., East Ham; J. R. CAVE, LTD.,Southport ; COOPER LABORATORIES, Watford ; CURTISAND Co., Baker-street, W.; CUXSON, GERRARD,AND Co., LTD., Oldbury, Birmingham; DUNCAN,FLOCKHART AND Co., Edinburgh and London;GALE AND Co., Bouverie-street, E.C. ; GALENMANUFACTURING Co., LTD., New Cross-road, S.E.;GOODALL, BACKHOUSE AND Co., LEEDS ; HANDFORDAND DAWSON, Harrogate ; HARRINGTON BROS., LTD.,City-road, E.C.; HODGKINSON, PRESTONS, AND KING,LTD., Bishopsgate, E.C.; JEYES’ SANITARY COMPOUNDSCo., 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. MARTIN-DALE, 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. ; PECKAND 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.; RICHARDSONAND Co., Blackpool ; JOHN RICHARDSON AND Co., LTD.,Leicester; F. M. RIMMINGTON AND SONS, Bradford;SQUIRE AND SONS, LTD., Oxford-street, W.; STANDARDTABLET AND PILL Co., LTD., Hove ; H. E.STEVENSON AND Co., LTD., London, S.E.; SYMES ANDCo., LTD., Liverpool ; TYPKE AND KING, LTD.,Mitcham ; THOS. TYRER AND Co., LTD., Stratford;WHIFFEN AND SONS, LTD., Battersea; WRIGHT,LAYMAN, AND UMNEY, LTD.. Southwark-street, S.E.

THE SEPARATION OF PRESCRIBING ANDDISPENSING.

To the Editor OJ THE l.JANcmT.

SIR,—In reply to the letter of Mr. J. 0. Braithwaitein your issue of Feb. 26th, the Ministry of Health Com-mittee of the Pharmaceutical Society admits, in its

report which appeared in the Pharmaceutical Journalof May 15th, 1920, that the only statutory qualificationin the dispensing of medicines is that held by the

apothecary’s assistant, also that the statutory qualifica-tion of the pharmacist for the dispensing of poisonsapplies only to open shops, and only to scheduledpoisons. A hospital or institution cannot be held to bean open shop. If there is to be any separation ofprescribing and dispensing the apothecary’s assistantcan justly claim priority to dispensing in any placesother than open shops.

I should like to point out that in the orders governingthe appointment of dispensers to many public hos-pitals, institutions, &c., the apothecary’s assistant is

equally eligible with the pharmacist, and in order ofprecedence appears before the pharmacist, and further,as a matter of fact he discharges his duties in theseplaces to the entire satisfaction of those concerned.Mr. Braithwaite seems to have overlooked the fact thatthe business of a chemist and druggist has many thingsin common with the herbalist and grocer, and if suchclassification is necessary the pharmacist certainly hasthe 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.

SIR,—In an annotation in THE LANCET of Nov. 30th,1920, figures are quoted from a paper by Professor S.Lyle Cummins, contrasting the rates for tuberculosisin the British Army with the much higher rate whichprevailed amongst the men of the South African LabourCorps, and using these as an illustration of. the

susceptibility of primitive races to a new disease andtheir inability to withstand its attack. This use ofthe figures is not justifiable in regard to South Africannatives at all events. In a paper written in 1911, aprecis of which appeared in THE LANCET of May llth,1912, 1 gave evidence to show that the great susceptibilityof South African natives to pneumonia and tuberculosiswas due to the great prevalence of a syphilitic taint inall native tribes in South Africa, and that they tookthese diseases in a virulent form. In a subsequentpaper (THE LANCET, April llth, 1914) it was shownthat a similar susceptibility, in a somewhat less degree,applied to the white population also. The ancient andoften-quoted example of the heavy mortality resultingin a " virgin soil " from such a disease as measles iseasily understood by anyone who knows the habits ofnatives when suffering from any febrile disease withoutputting 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 Robertsin THE LANCET of Feb. 26th has touched me in amarked degree. The author of " Chronicle of a CornishGarden," a fellow-student of mine some 30 years ago,concentrated his early energies in the congenial air ofa wide and wild part of England, only to remove laterto the drab and depressing atmosphere of an East-enddistrict. No wonder he unconsciously contrasts, in hismind, the almost undisguised worship of a simple andkindly country-folk with the more shrewd and criticalaudience of the town wage-earner. Perchance if he hadpractised first in the sordid surroundings of some vastcity and then transferred his sphere of action to thefree and open country his opinions might have beenreversed, and he might even have thought the status ofthe general practitioner had risen rather than descended.But there is great truth in his letter. The political

reformer who dreams wonderful visions of an idealorganisation for both the public and the practitioner isusually just the man who has never had any personalexperience of private practice. How many generalpractitioners, I would ask, represent our profession inParliament? As is usual among this type of man, inhis overflowing enthusiasm and concentration he doeseverything of which he can possibly think but " theone thing needful." The machinery is all most perfectlymade, of the finest metal, intricate, beautiful andwonderful, but, alas, those little drops of oil, that areso essential for it to run smoothly and wisely, havebeen forgotten, and sooner or later it is doomed to beplaced on the scrap-iron heap. The vital factor in thelife of medical practice is the relationship between thedoctor and his patient. You may organise veterinarysurveillance for a flock of sheep or goats and theycannot demur. Human beings are different. Theycan and will demur. The panel kills or stifles thatfine professional relationship which every self-respect-ing medical practitioner unconsciously seeks. The

patient, instead of being an individual, becomes merelyan integer. The democratic Briton, whoever he may be,will not tolerate this. He has to put up with it for atime, as there is nothing else to fall back upon, but event-ually, I feel convinced, he will resist it to the uttermost.

I agree with Dr. Roberts that by far the vast numberof practitioners are keenly alive to the Hippocratic oath,and by far the majority, under particularly adversecircumstances and often against tremendous odds, willmaintain 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 thedifficulties and position of a country " club-doctor."A certain number of club members take up an attitudethat because you are a club-doctor you are unable orunwilling to do justice to them on account of the smallfees paid. Their prejudice leads them to think theyare not receiving the best attention and, in the case ofa protracted illness they will sometimes call in anotherdoctor who they imagine may render them greater

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assistance, as they will be paid for their services by’" piece-work." This, in many cases, is most dis-heartening for the club-doctor who is giving his bestattention under, perhaps, difficult and adverse circum-’stances. What is he to do P He is in the grip of arelentless system over which he has no power to cope..And yet there are others. One, in particular, I

remember, who after a long illness, from which heslowly recovered, told me:

" I shall always respect you,Sir, for what you have done." This, from Dr. Roberts’s’View-point, was a success, though from a materialisticstandpoint, no doubt, was a failure.In practices such as Dr. Roberts appears to have it

is a constant and continuous " casting of one’s breadupon the waters," but I do believe if we are faithful tothe highest ideals of our profession, we see it back,again, even though it may be

" after many days." Onecan only have unceasing admiration for those of our)profession who are fighting to keep alive their spirit-;instincts among an uncongenital society and in im-possible surroundings. Are they not the very salt of.our profession and are not these the men that havetgiven to our profession in the past the splendid name it!has won and will, we believe, carry it on unblemishedAo the end of all time ?-I am, Sir, yours faithfully,

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 ofa nerveless automatism in visceral action had beeniplayed out, and if a few actors still reluctantly with-draw from that deserted stage and with a silence withwhich positions once held are abandoned, the curtain isdescending and the footlights on that play are growingdim. But all the bustle of an entertaining piece stillanimates the discussion of the parietal expression ofvisceral pain. The interest, moreover, in this matter isnot only professional, for a long-suffering public, rendered’valetudinarian, is regaled with this mystery even by thelay press, the Times being most obtrusive in itsadulatory appreciation of the parietal interpretation ofvisceral pain. In due course, however, and with a likeconclusion, 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 thelatter the clinical may, perhaps, be regarded as themore trustworthy.

The conclusion reached in your article is that visceraare capable of being the site to which pain is referredunder certain circumstances, notwithstanding the well-known peculiarities of their sensibility. You, therefore,subscribe in this matter, and I think with more justicethan is often the case, to the truth of the saying,Securus judicat orbis terrarum. That is, that the " manin the street " with nephritic colic or angina pectoris isaware 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 ofone of your correspondents (Feb. 6th), this chief pointhas been ignored by most of your correspondents, whoappear to be more occupied with the existence anddiagnostic value of the parietal and segmental tender-ness 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 onthe embryology and innervation of the serous surfacesor " inpacked " " skin " which forms the capsule of theviscera ; hence, he demurs to Dr. A. F. Hurst’s con-clusion, that the viscera are themselves sensitive, givenan " adequate stimulus." To accept Sir Clifford Allbutt’sview would be to agree that, unless the investment ofviscera be affected, there can be no visceral pain andthat all intrascapular visceral innervation is motor incharacter or function. Even the acutely painfulthrombus in a coronary artery hurts, according to him,because of a stretching of the pericardium, whichjhe regards as ensuant. How does this conclusion

agree with Cannon and Washburn’s demonstration ofthe association of hunger-pains with gastric contraction?In this case the capsule is relieved of tension during thepain not stretched. The tension here is in the con-tracting muscle. From clinical evidence it may beasserted with confldence that pain during an attack,whether of angina pectoris, acute appeudicitis, nephriticor biliary colic, or any other visceral agony is deep andreferred by the patient, as well as determinable by thephysician, to be subparietal. The surface aftermathbut proves that the circumstances which induce visceralpain reveal the existence of paths in the autonomicnervous system afferent to centres, spinal and cerebral,which are usually denied to exist except in very limitednumbers. That the visceral nerves are mixed nervesmay, however, be shown anatomically.More than 20 years ago, when delivering the Morison

lectures in Edinburgh, I showed that " the nerves

which innervate the pia mater are anatomically similarto those which follow, twist round and end on vessels,and may occasionally be actually seen to take theirdeparture from the nerve on the vessel." It will beadmitted that if the vessel be a motor organ thepia mater certainly is not, and that its innervationtherefore belongs to the sensory group, howevermodifled from the somatic type of the same series. I

may remark, in parenthesis, that the intracranialvessels were at that time regarded by physiologists asnerveless and muscular automata. They played,indeed, a leading part in the drama now withdrawn, towhich I have already referred. I have also shown thatthe innervation of the coronary artery is submuscularas well as perimuscular-intravascular as well as extra-vascular-and that the mode of termination of visceralnerves, whether capsular or intracapsular, is the same.2My anatomical and clinical experience, therefore,

has strengthened me in the position I have long main-tained and published, on what have appeared to me tobe sufficient grounds-namely, that the site of visceralpain may be not only capsular or peri-organic but alsointracapsular and organic. With this view the leadingarticle already referred to seems to be in agreement,although it does not appear to show acquaintance withmy 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 HowardMcFadden, who died at Philadelphia on Feb. 16th,aged 70. He was an unostentatious philanthropistwho helped to make progress. Although he was attack-ing a problem which he could scarcely hope to solve,he cheerfully started and entirely supported for sixyears a cancer research organisation at the ListerInstitute of Preventive Medicine in London. He gavecarte blanche, and later on extended the investigationsto other branches of medical research-for example,sending expeditions to investigate pellagra in theUnited States. The researches made in associationwith the Home Office into the cause of industrialcancer at briquette works are to the credit of Mr.McFadden, who received the thanks of the Secretaryof State for what he called his " spade-work," buthe never courted publicity. He was a remarkablepersonality. Equally known in the great cities of

Europe and America, he was a sort of "Mr. Potter ofTexas," with the sombrero replaced by a silk hat andthe revolver by kindness. A cotton magnate, heenjoyed to act the part of an American millionaire.He was a daring speculator, being usually " bullish "when others were " bears," and on one occasion atleast he averted a panic in the Cotton Exchange inNew 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 hewill 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.