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standards. Dr. McCleary says of the sixpennydoctor :

" Sometimes he was English ; not infrequently he wasScottish ; more rarely he was coloured ; often he spokewith an Irish accent. Usually he began with what wascalled a ‘ nucleus ’ and if successful he would develop hisnucleus into a lucrative practice, which he would sell andwith the proceeds buy a practice in a genteel suburb...."

Sixpenny doctors worked exceedingly long hours,and at speed, doing their own dispensing from stockmixtures-for a bottle was a part of the bargain.Sometimes they gave Sacchar2cm Ust’urn,

" a medicament

which possesses in a high degree what Hippocrateslaid down as the first essential of medicine-that it shoulddo no harm." Dr. McCleary, who served as a locuin inseveral such practices, is cheerfully unrepentant aboutthese bottles of burnt sugar.

" When I think of the vast quantities of heart-depressingcoal-tar drugs that are swallowed annually in self-medica-tion by an unreflecting public, I recall with satisfactionmy dispensing of Saccharu7n Ustum with its reassuringcolour and complete harmlessness of effect."

Once he worked in a practice in North London wherethere were two waiting-rooms, one for the sixpennypatients and another for those who could afford to paya shilling. The doctor saw two shilling" patients forevery sixpenny patient, so the higher fee saved the

patient a wait. The clientele in the two rooms varied

according to the ready money at their disposal at thetime ; there was no feeling of class distinction about it.

Dr. McCleary would not have us think these doctorswere inefficient or careless :

". Some of the men for whom I worked were skilled,conscientious, and laborious, who loved their work and didtheir best for their patients. They had developed a time-saving technique and a flair for distinguishing the importantfrom the unimportant."

He suggests that Flaubert might have made a classicof the life of one of these doctors. Some will recalla less ambitious work-Sixpenny Pieces, the modesttribute of Neil Lyons to Harry Roberts, in Stepney.

ADRENOCORTICOTROPIC HORMONE AND

HYPERSENSITIVE REACTIONS

IT is sometimes forgotten that the symptoms of diseaseare produced not directly by the external or internalnoxious agent which is acting but by the body’s reactionsto that agent. Even when there is a definite bacterial orvirus cause, the clinical picture-the malaise, fever, pain,and local inflammation-is that of the body’s attempt tocombat the attacker. In some diseases, of which thosecalled allergic are the most striking example, though theyalso include the rheumatic group, periarteritis nodosa,,and others-the body’s reaction is out of all proportionto the severity of the attack and is therefore called a"

hypersensitive " reaction. In these, if the reaction can

be abolished the " disease " is cured-at least for thetime being. A few years ago Hughes 1 suggested that inacute rheumatism any " poison " which would abolishthe body’s reactivity without doing any permanentharm would produce a cure : in his view this explainedthe action of salicylates in rheumatic fever.

The same principle-of treating disease by moderatingthe body’s reaction-is behind the use of antipyretics ingeneral, and of ’ Cryogenine ’ in particular ; and Dr.

Geoffrey Bourne showed in these columns last week thatreduction of temperature with this drug can improvethe condition of patients with lymphadenoma, rheuma-toid arthritis, or tuberculosis.The vast amount of work being done in the U.S.A.

with A.C.T.H. and" Cortisone ’ suggests that one impor-tant effect of these substances is to block hypersensitive

1. Hughes, W. Ann. rheum. Dis. 1942, 3, 89.

reactions. This may explain the observations, made(though still unpublished) in a wide variety of diseases,that A.C.T.H. immediately abolishes the malaise asso-

ciated with them ; it may also be the basis of the goodresults reported by Hench and his co-workers 2 inrheumatoid arthritis and acute rheumatic fever. More-

over, Bordley and his colleagues 3 at Johns Hopkins havenow reported remarkable results with A.C.T.H. in allergicdiseases. The rapid recovery of a patient critically illwith exfoliative dermatitis due to iodine led them totry A.C.T.H. in a case of penicillin sensitivity of serum-disease type, in which the giant urticaria, joint pains,and fever disappeared within 24 hours. They thenobtained equally rapid relief in five patients with severechronic asthma which had not responded to adrenaline,theophylline and ethylenediamine, or rectal ether. Infour of these the symptomatic improvement was accom-panied by the return of a pale cedematous polypoid naso-pharyngeal mucosa to an appearance not far from normal.In accordance with the experience in rheumatoid arthritis,the patients tended to relapse 2-3 weeks after theircourse of treatment. ’ .

THE "BURR" RED BLOOD-CELLHaeMATOLOGISTS are familiar with the spherocyte, the

round fat red cell of haemolytic anemia, and with the"

target " cell, the thin red cell of Mediterranean anaemia,so thin that its sides clap together somewhere about themiddle and make it look, in transmitted light, like aScottish shield or target. Then there are the sickle-shapedcells associated with a familial anaemia in negroes, theoval cells which are also familial, and one or two otherodd shapes of no particular diagnostic import have beendescribed from time to time. The latest addition is the" burr " cell of Schwartz and Motto,4 which is said to befound only in patients with certain diseases, particularlywhere kidney function is impaired.The burr cell is a kind of, poikilocyte. It is a red cell

of normal size with one or more spiny projections alongits edge ; the projections are quite long, varying fromabout a sixth to half the diameter of the red cell, andphotographs show that they are usually sharp andpointed. So it does vaguely resemble the burrs that stickto our clothes or the coats qf our dogs. Burr cells arenot just crenated cells ; they are fairly evenly scatteredover the blood-film, whereas crenated cells tend toaccumulate in groups. The blunt-processed burr cell maywell be difficult to distinguish from a crenated cell, sono cells should be counted as burr cells unless they areapart from crenated groups. Schwartz and Motto foundburr cells in the blood particularly in cases of uraemia,carcinoma of the stomach, and bleeding peptic ulcer. Outof 75 uraemic patients 54 had burr cells in their bloodsmears ; out of 50 with carcinoma of the stomach 34had burr cells ; and the cells were seen in 27 out of 50patients with bleeding peptic ulcer. Two control serieswere studied ; the first comprised 100 consecutive blood-films from patients admitted to the medical wards forsome condition other than a blood disease ; the secondwas made up of 100 patients who had some haematologicalabnormality. No burr cells at all were found in the firstgroup, whereas 21 patients in the second group had them,and the only common factor in these 21 patients wasrenal impairment.What it is that causes red cells to throw out spinous

processes has not yet been determined. Severity of theanaemia, duration of bleeding, degree of nitrogen reten-tion, dehydration, age, sex, and race, have all been

2. See Leading article, Lancet, July 23, p. 159.3. Bordley, J. E., Carey, R. A., Harvey, A. McG., Howard, J. E.,

Kattus, A. A., Newman, E. V., Winkenwerder, W. L. Bull.Johns Hopk. Hosp. 1949, 85, 396.

4. Schwartz, S. O., Motto, S. A. Amer. J. med Sci. 1949, 218,563.