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Special Articles

PATHOLOGISTS AT THE CROSSROADS*D. F. CAPPELL

C.B.E., M.D. Glasg., F.R.F.P.S., F.R.C.P., F.R.S.E.PROFESSOR OF PATHOLOGY, UNIVERSITY OF GLASGOW

* From the presidential address to the Association of Clinical

Pathologists on Sept. 30, 1960.

AT the present time there is much very sincere, yetsorely troubled thinking about the future organisation ofpathologists.For the title of this address I use the words " at the

crossroads " with full realisation that a crossroads is a

place from which one can proceed in a variety of direc-tions-onwards to a new destination, to right or to left, orjust plain backwards. Before we can reach any validconclusion about what course to pursue, we must try tounderstand the causes and the distribution of the presentdiscontent among pathologists.So far as I can ascertain, the unrest is chiefly on the part

of the younger consultants in hospital pathology and thosewho have not yet reached that rank; but many of the moresenior men, and some academic pathologists also, haveengaged themselves in the matter actively because theyare anxious to do everything in their power to ensure thatthe pathologist of the future shall be able to enjoy aprofessional career in the most favourable circumstances.

* * *

In thinking of the pathologist, whether at the crossroadsor elsewhere, we must first take into account the nature ofhis work, and this seems to me to fall into two mainclasses. Pathology has been defined very generally as thestudy of disease by scientific methods, and it has two mainpurposes-namely (1) to advance fundamental knowledgeof the nature of disease and of the mechanisms by whichdisease is produced, and (2) to apply existing knowledge tothe diagnosis and prevention of disease with a view tofacilitating treatment, even if the latter is not properly theconcern of the pathologist in other than an advisorycapacity. It may be that one of the causes of presentdiscontent lies in the drift apart of these two functions, asDible has stated, and we should inquire into the practiceof clinical pathology in this country to see whether we canimprove it and remove the causes of the disquiet.The continued advance in technical methods has

multiplied very greatly the demands upon the laboratoryfor routine tests, and there are few laboratories, if any,where the technical staff has grown in proportion. Severalof our most distinguished colleagues have expressedanxiety on this score and deprecated the almost total

submergence of the clinical pathologist in carrying outroutine tests at the behest of the clinician-a positionwhich may well induce a feeling of inferiority if the

pathologist has no say or choice in the selection of thework he has to do, and allows himself to be used as onewhose work is merely ancillary to that of the clinician.There is no single remedy for this overloading of existingresources; but as far as possible merely technical workshould be allotted to technicians, so that the pathologistshall have more time to widen and advance his funda-mental knowledge as an exponent of one of the basicsciences of medicine on which clinical work is founded.The medical and technical staff of hospital departments

has all too often been kept at so low a level that energiesare wholly spent in getting through the day’s work, and

this is all the more true when the duties involve so-called

emergency calls at night and at weekends, not all of whichare real emergencies. The clinical pathologist could beprotected by the senior clinician from exploitation of thiskind; but such discrimination and care are less likely to beexercised on his behalf if the pathologist allows himself tobe relegated to the position of a mere servant of the wards.The volume of hospital work has increased by virtue of

a law that antedates Parkinson-namely, that the success-ful research of today becomes the routine of tomorrow.It is not so long ago that the pathology department of thehospital was known as the research department, and it ispart of our duty to see that the title shall continue to beworthily applied. * * *

It is to the credit of pathology that it brought medicinefreedom from the shackles of Galenic authoritarianism;and it is still true that research in the laboratory in one orother of the four branches of pathology is the chief sourceof the increase in scientific clinical knowledge that is sostriking a feature of medicine today.The first of its four constituent disciplines to develop

was morbid anatomy; and the morbid anatomist and

histologist was trained largely on the apprenticeshipsystem, rather unsystematically, but with lots of room forindividuality. Of all the divisions of hospital pathology,the diagnostic problems in morbid anatomy and histologyare the most exacting and the most personal. There are nocontrols, there are no tables of biological reactions suchas can be applied to bacteria, and there are no standardsolutions such as the chemist uses to check his results andset his confidence limits. There is only the pathologist,the sections, and the microscope, and his experience toguide him.

Bacteriology was the second of our disciplines to evolve;and, although much of the routine hospital work can becarried to the reporting stage by the trained technicians,hospital bacteriology offers a rewarding field to the trainedand inquiring mind in the tracing of outbreaks of infectionand eradicating the causes, in ensuring sterility, in

controlling cross-infections, and in understanding howand why bacteria come to cause disease, and how it can becured or averted. In addition, more academic biologicalbacteriology is also open to those whose interests lie inthat direction. I shall no more than mention virology-a younger relation of bacteriology but one rapidly goingits own way. The interactions of bacteria and viruses

present fundamental questions of which we have onlybegun to glimpse the answers.

Hsematology is the discipline that has retained theclosest connection with clinical medicine; and indeed it isstill practised by physicians to such an extent that thisdivision of clinical pathology sometimes operates moreunder the department of medicine than of pathology.Here too the rapidly advancing technology of the subjectis tending to lead to greater specialisation, and I believethat general physicians are gradually handing over moreand more of the routine investigation of all hxmatologicalproblems to that division of clinical pathology. In viewof the ever-increasing complexity of the blood-groups andof cross-matching techniques, of the progressive sub-division of the clotting factors into more and more frac-tions of clinical significance, and of the elaboration oftechniques for the investigation of hxmolytic anxmiasand of types of hxmoglobin, it is not surprising that thephysician turns more and more to the professional laboratoryworker. A certain amount of robot working by electronic

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machines has already been introduced and no doubt moreis to come, but there is a large and expanding area in whichexpert knowledge is required and for which specialisedtraining must be provided within the laboratory.

Our fourth subdivision, chemical pathology, presentsspecial problems. In it, as in bacteriology, a large part ofthe routine hospital work can be and is increasingly carriedout by technicians and other workers not medicallyqualified. In this field we have recently seen the firstserious attempt to introduce automation, and it seems

likely that robot analysis will become more popular inhospital departments where large numbers of simplerepetitive tests have to be carried out for the control ofclinical treatment. Much of the routine chemical pathologyof hospital departments can therefore be carried out byworkers who are capable of following given directions andare able to assess the accuracy of their results by the useof standardised solutions as controls. Like all simplerepetitive work this is unlikely to hold the interest of alively mind for long; but before the medical graduate cango further in chemical pathology he requires a greaterbasic knowledge of chemistry and of biochemistry.Without a science degree, he needs further fundamentaltraining, which it is almost impossible for him to receivewhile engaged in full-time hospital work. The Associationof Clinical Pathologists was able to persuade the Ministryof Health that aspirants to chemical pathology might beseconded at the registrar stage for a year of fundamentalstudy in chemistry while receiving full pay. It is hopedthat this will enable the supply of would-be chemicalpathologists to be increased, but it is as yet too early toknow whether the scheme will succeed.

* * *

We can lay down, therefore, a general pattern of

development for the young pathologist in training-thathe should be given the opportunity to acquire a certainfoundation of experience in each of our four disciplinesand thereafter take up whichever branch of work hisinclinations and opportunities favour. If during this timehe can be given a problem to pursue, so much the better.Every effort should be made to encourage this activity.I am convinced that the hospital pathologist will be abetter man and will do a better job in his daily routine ifhe succeeds in combining some research interest with hisdaily work as soon as he has mastered the initial rotationaltraining. I do not advocate that he should write for thesake of writing, but much valuable observational researchremains to be done.What of the other side of pathology, the so-called

academic side? Here teaching and research are the

predominant interests and it is the duty of universities tofoster them. Where university and hospital appointmentsare combined, the professor, and especially his fairlysenior staff, should not be so overburdened with routinehospital duties that their primary purpose is defeated.Nowadays most professors are glad of a share of the routineas a happy relief from committee meetings and administra-tion, but the lecturer staff can suffer badly unless they areprotected by their terms of service.

* * *

We have glanced briefly at the training that the youngpathologist is likely to undergo nowadays. At the end of itwhat has he got to show that he has successfully completedthe round and had further experience in one or morefields ? If he has stayed in an academic department andbeen fortunate in his research he will probably have anM.D. or other higher degree by presentation of a thesis on

a selected topic. But what of the man who has not been ina teaching department but has been busily engaged inhospital pathology for five years or more under a goodgroup of consultants who have taken the trouble to

supervise his training and experience ? It appears that hefeels a sense of frustration, and sees himself at a disad-vantage as compared with his contemporaries in medicineand surgery, because they, after a comparable period oftraining are likely to have acquired the M.R.C.P. or F.R.c.s.This feeling is likely to be intensified when he hasattended a few appointment committees and had to

explain why he has no higher qualification. This sense offrustration is one of the most potent causes of unrest today.

In what ways are pathologists made to feel that theirposition is regarded as inferior ? Regarded by whom ?Not by themselves, unless they have a guilt complex andfeel that they occupy a position of equality that is un-deserved. Nor by the administrative authorities; for theyhave admitted equality in the only way they can, byawarding full consultant status and equal pay. Neverthe-less there is a substratum of truth to be uncovered.

In the pre-N.H.S. days there was a widespread customin England, if not in Scotland, of regarding as ineligiblefor appointment to the medical staff committee of thehospital anyone in receipt of a salary, even part-time.The non-academic pathologist, to survive at all, wasnecessarily in receipt of a salary because, in contrast withphysicians and surgeons, he had only a -very restrictedscope for earning a living by private practice. In manycases this meant that the pathologist was excluded fromparticipation in hospital affairs on equal terms with hisclinical colleagues because he was thought to have a vestedinterest. This unwarranted prejudice has, I believe, leftits mark on staff relationships to this day. The patholo-gist’s salary was usually part-time and his income had tobe supplemented by private practice in clinical pathology,for which he was again dependent on his clinical colleagues.

This continual carrying out of tests at another’s bidding,and providing results to establish a clinical diagnosis forwhich the pathologist may receive little acknowledgmentor credit, may have depressed some clinical pathologist’sassessment of their own position. I think this is false andunworthy, for if the clinical pathologist so hankers afterultimate responsibility for the care of the patient that heis unhappy without it, he is in the wrong section of theprofession. Having chosen his field of work he cannotreasonably grumble if it does not cover those parts ofmedical practice in which he finds his deepest interest. If

prejudice of that kind still survives, surely it must be

dying out. Physicians and surgeons, too, are now paid fortheir hospital services, either full time or part time, andtheir position is in no way different from our own.The other chief cause of dissatisfaction however is,

worthy of more detailed inspection-namely, the lackof a specific higher qualification in pathology to testify to ageneral level of professional competence in the chosensubject.

* * *

Higher qualifications in pathology have been underactive debate in the Association of Clinical Pathologistssince 1947. Many pathologists have expressed the desire

: for such an examination in the belief that successfulcompletion would give them additional status, if only theexamination could be universally recognised as of equal

. standing with the M.R.C.P. By status I understand them

. to mean that they are thereby acknowledged to belong tol a professional organisation or society which is of high

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repute, and is therefore presumed to shed some of itslustre on them. It is equally true, however, that the reputeof a society depends on that of its constituent members,who by their professional activities determine the placethat the society will be accorded by similar professionalorganisations and within the community.The comparison most frequently made is with the

higher qualifications of the Royal College of Surgeons andthe Royal College of Physicians; and so the demand is forsomething that will not be called merely a diploma,although of course all of them are diplomas. The higherqualifications of these old-established corporations haveattained their enviable position at least in part because ofthe difficulty in acquiring them, as is attested by pass-rate of 10-15%. Further it is now insisted by the collegesthat the possession of these higher qualifications is not tobe regarded as anything more than an indication ofsuitability to undergo further training in clinical medicineor surgery. For this reason many have advocated that theM.R.C.P. should be taken before embarking on a career inpathology, for its value as an indication of quality isbeyond doubt.But is the M.R.C.P. the proper examination for a

pathologist already in training? This is by no meansuniversally accepted.The academic affairs committee of the Association was

unanimously of the opinion that the M.R.C.P. as it standscould not be regarded as a suitable qualification in

pathology. This implies no disrespect-the examination isnot designed for that purpose. Further, the evidencesubmitted to us left no doubt that, after a few years ofenthusiastic encouragement of their juniors to go for theM.R.C.P., many consultants in pathology had changedtheir point of view and were now convinced that thisexamination ought to be taken, if at all, before embarkingon full-time laboratory training. The reasons for this

change of mind are not difficult to find. The high-levelclinical examination required of an intending physician isa serious problem for the man who has been working inthe laboratory for a few years, for it requires not only theinitial education of the senses but the maintenance of skill

by constant practice. I have on occasion suggested toclinical examiners that a distinction should be drawnbetween knowledge of medicine, combined with ability tointerpret the history and physical signs, and the technicalability required to elicit and detect the physical signs.This is, after all, the technical skill of the physician, andit is no more justifiable to demand it of the youngpathologist than it would be to require the physiciantaking the M.R.c.P. to perform personally all the laboratorytests thay he quotes so glibly. So long as the M.R.C.P.examination remains in its present form-and there is noprospect of changing it-we must accept that it is not ahigher qualification in pathology, however desirable it maybe as an indication of general ability and suitability forspecialist training. Unless success comes quickly, theeffort required to keep up the clinical skill is too great tomake it a practical proposition while doing a full day’swork in the laboratory. Many heads of departments havehad the painful experience of seeing a young man ofadequate ability fail to pass at his first or second attemptand thereafter become virtually a passenger in the

laboratory until this hurdle had been surmounted.* * *

After the debate at Exeter in 1953, inquiry by thecommittee on training of clinical pathologists revealedgrave dissatisfaction with the standard of would-be

entrants into laboratory work. It was surprising that ata time when promotion in the clinical field was slowerand more difficult than ever, there should have been suchlack of high-class recruitment into a specialty which wasclearly going to expand and was likely to allow promotionto consultant status at an earlier age than in generalmedicine or surgery.The shortage of applicants was not universal. I do not

think it was experienced by all university departments,and at least we in Scotland had no real difficulty inmaintaining the high academic standards to which ourdepartments had been accustomed in pre-N.H.S. days.In this we were, I realise, in a privileged position, verydifferent from that of some non-teaching hospital depart-ments, which were inadequately staffed by technicians,insufficiently supplied with apparatus, and generally atthe tail-end of any list of priorities for building or equip-ment. In thus starving the laboratory service, and almostdepriving the pathologists of hope that the rapidlymounting burden of routine work could ever be undertakenin reasonable conditions, the responsible authorities,whether central or local, did pathology a grave disserviceand one that is not yet removed. Recent graduates of highability and promise were discouraged from entry to

hospital pathology, and senior consultants in turn weredepressed by their failure to attract men and women ofthe right type.At this time the cry was again raised that a material

factor in influencing high-quality graduates to rejectpathology as a career was the absence of a suitable higherqualification comparable to the M.R.c.P. or F.R.C.S. Inwhat ways then, apart from personal pride and satisfac-tion, does the absence of a higher qualification affect

pathologists ?The Health Service Acts have rather’ elaborate

machinery for the filling of all posts of senior-registrarstatus or higher. In England and Wales representativesof the Royal Colleges sit on all committees for consultantand S.H.M.O. appointments, and in Scotland the procedure,although different in detail, is much the same in practice.Thus it has come about that at committees for the

appointment of a pathologist it is not uncommon forcandidates who have no higher qualification of any kind tobe asked to explain why this is so. Indeed, even whenthe candidate has the M.D. degree, sometimes it is

suggested that this is not an adequate higher qualificationbecause it may have been taken by thesis in a narrow andhighly esoteric field of study that affords no guarantee ofknowledge and experience in a wide professional field,however much it may indicate intrinsic intellectual ability.The standard exacted by the universities varies and

their degrees are not strictly comparable. Some confer

only a pass degree, others award in addition two gradesof honours and beyond that, for the highest class, a goldmedal. Furthermore, the circumstances under which athesis is written must influence one’s assessment of itsmerit, for the award of a pass degree to a candidate withall the resources of a university department behind himindicates a less meritorious performance than a similaraward to a man working in a peripheral hospital laboratorywith fewer facilities at his disposal. Whatever mayevolve, I hope that we shall never reach the position thatthere is only one portal of entry into hospital pathologythrough which all must pass by virtue of a specific

: examination. This would, I fear, canalise the entry far tool narrowly. The academic departments are relatively few,: but the opportunities they offer for scientific training are

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of the highest class. Since promotion for all to a pro-fessorial chair is impossible, there must be an outlet fromacademic pathology into hospital pathology, and it isthe duty of the heads of academic departments to ensurethat the training of their staffs fits them to make thetransfer if they so wish.

* * *

As a first approach to a solution of the problems beforethe Association of Clinical Pathologists, the council in1953 set up a committee on academic affairs under thechairmanship of Prof. Geoffrey Hadfield to consider theadvantages and disadvantages of a College or Faculty ofPathologists, the possible membership and affiliations ofsuch a body if formed, and the practicability of higherqualifying examinations. The deliberations of this bodyand the views of its members and observers and of thecouncil were presented to the Association in March, 1955,in a masterly report by the then chairman of council,Dr. Cuthbert Dukes, and this report was circulated to allmembers of the Association. The conclusions thenreached by an overwhelming majority were (1) that it wasimpracticable and inexpedient to attempt to set up anindependent college or faculty at that time, (2) that anaffiliated faculty under the conditions then prevailing wasundesirable, and (3) that the whole question be kept underreview. It has, in fact, been under review ever since.

Although there was general agreement to shelve thequestion of a college or faculty for a period, it was feltthat there was need to encourage a more systematictraining for new entrants and also to review all the avail-able higher qualifications to determine whether any ofthem met our needs. A new standing committee onacademic affairs which was set up studied the existingexaminations and explored also the possibility of an

examining board on the lines of the American system. Ofthe existing examinations the most suitable seemed to bethat of the Royal College of Physicians of Edinburgh, inwhich the candidate professes a special subject selectedfrom a list that includes pathology. But even this examina-tion is not ideal; it includes a normal membershipexamination in clinical medicine and a good deal of

pharmacology and therapeutics. All attempts failed to

persuade the Edinburgh college to modify the examinationto our requirements by increasing the pathology at theexpense of clinical medicine and pharmacology. Thusthe Edinburgh M.R.C.P. is actually more difficult for a

young pathologist than for a young physician; for the

pathologist has to attain the necessary standard both inclinical medicine and in pathology.As a result of all these deliberations the committee on

academic affairs came to the conclusion that none of the

existing examinations fully met our requirements and thatnone of the licensing bodies was prepared to modify anexisting examination to our wishes, or to institute a newand acceptable examination for us. For example, con-versations with the Royal College of Physicians of Londonindicated that there was likely to be no great difficulty ininstituting a new higher qualification such as a mastershipin pathology, but this did not include the offer thatsuccessful candidates would thereby qualify for sub-

sequent election to fellowship. Since this appears to bethe yardstick by which any examination conducted bythe Royal College of Physicians is judged, the proposedmastership was deemed unsatisfactory.The academic affairs committee then recommended

to the council in April, 1958, that official conversationsshould be begun with the Pathological Society and with

the Royal Medical Corporations on the question of post-graduate qualifications in pathology and especially onthe nature of the supervising and examining body requiredfor the purpose. This left the door widely open for anyapproach or discussion. The matter did not long restthere. At the council meeting in June, 1958, resolutionswere submitted from three branches requesting thatsteps be taken forthwith to establish a new body or collegeto represent pathology. The council, despite the over-whelming body of opinion against such a proposal onlythree years previously, agreed to set up a " ways andmeans " committee, under the chairmanship of Prof. G. J.Cunningham to examine and report on how a College ofPathologists might be inaugurated. This committee workedat great speed and reported to the council in October,1958, on (a) the procedures by which a college might beinstituted, (b) the estimated cost of a college in CentralLondon, and (c) the functions that a college ought tosubserve.The committee recommended a referendum to the

Association as a whole to determine whether a substantialmajority of members now favoured the proposal to set upa college, and, if so, whether they would contribute to itfinancially. It was also recommended that an approachbe made to the Pathological Society to ascertain the viewsof pathologists other than those practising clinical or

hospital pathology. The next step therefore was to prepareand send out to all members a voting paper; but thecouncil laid it down that they could not consider them-selves as having a mandate to pursue the matter furtherunless 75% of the ordinary members voted and of thosevoting not less than 75% answered all the questions in theaffirmative. At the end of the day these requirementswere not actually fulfilled, but the margin of failure wasso small that the council agreed to go to the next step-i.e., to try to acertain the views of pathologists otherthan our own members.The Association of Clinical Pathologists is, of course,

only one, and the junior one at that, of the two mainsocieties that concern themselves with pathology in GreatBritain. According to its constitution the PathologicalSociety, our senior by twenty-one years, has as its object" to advance Pathology and to facilitate intercoursebetween pathologists ". I am unable to see that thisconstitution in any way precludes the Pathological Societyfrom expressing an opinion on the desirability of settingup some new organisation in pathology and even of

participating in the project. The membership of thePathological Society was circularised, and, although amuch smaller percentage of their members voted, therewas a fair measure of support and not much firmlyexpressed opposition to the proposal that somethingshould be done. The Pathological Society includes somany more research and academic pathologists and over-seas members that its point of view is not likely to beidentical with that of the Association, but at least it wasnot in violent opposition. The council was therefore

preparing to make further inquiries about the ways andmeans of achieving the desired result when a new andunforeseen complication-or perhaps simplification-emerged.

* * *

Shortly before the council was due to meet at the end ofJune, 1959, the chairman of council received a letter fromthe President of the Royal College of Physicians ofLondon indicating that he was aware of the desire ofpathologists to have an organisation of their own, and

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accepting their complete right to do so if they so wished.He proposed, however, the alternative solution of a closeliaison with the Royal College. Though he confirmed theimprobability of any modification of the membershipexamination for the benefit of pathologists, he acceptedthe important and to us essential condition that underany arrangement pathologists would not find themselvesin a position within the college inferior to that of physicians.How then could doubts about equality of position be

removed ? Here I think we must give great credit to thePresident for realising that the college would have to bewilling to demolish the barrier that made the previouslysuggested mastership in pathology unacceptable-namely,its failure to confer that privilege which alone testifiespublicly the recognition of equality that is so earnestlydesired. I refer, of course, to eligibility for election tothe fellowship of the Royal College. And the Presidentfurther professed his belief that, if accepted by the

college and the pathologists, equality would be to thebenefit of both branches of the profession.Faced with this unforeseen new situation the council

continued the working party under Professor Cunning-ham’s chairmanship, and added to it the senior secretaryof the Pathological Society as an observer. In the previousyear-i.e., before the letter from the President of the

Royal College had been received, the working party hadalready gone as far as it could in collecting informationabout the formation and financing of an independentcollege. Our inquiries had made it clear that a very largesum of money would be needed to found a college oneven the most modest and economical scale, and that itsrunning costs would be substantial. Pathologists bythemselves could hardly provide it without cripplingthemselves by a permanent covenanted annual sub-

scription of which my personal estimate is somethingsubstantially more than the figures in document B.

Therefore some external source of money would haveto be found. Given a case-iron case, perhaps it couldbe found. But before the council officially, or even

individual members unofficially, could approach wealthyand philanthropic individuals or Foundations to solicita substantial donation towards the formation of a college,it is essential to be able to proclaim that there is an

overwhelming need for such an organisation and thatthe project commands the enthusiastic support of thegreat majority of those who practise that branch ofmedicine. Were these conditions fulfilled, there are

avenues of approach that might be explored, but thecouncil was not then and is not now in a position to makeeither claim. Although a considerable body of opinionfavoured a college, this opinion had been obtained at atime when there was no alternative possibility in sight.The letter from the President of the Royal College intro-duced a new factor that had to be considered, and theworking party-in my view rightly-proceeded first toformulate the essential requirements of pathologists thatmust be met by the Royal College of Physicians in orderthat the proposals might be subjected to detailed considera-tion and presentation to the members of the Associationas an alternative to an independent college.Accordingly negotiations have gone on in some detail

and the results of these have been summarised in an

agreed statement from the representatives of the Associa-tion of Clinical Pathologists and of the Royal College.From this it is seen that the representatives of the RoyalCollege of Physicians are willing to recommend that therebe set up within the college a faculty or division of

1. Abnormal Haemoglobins; p. 387. Oxford, 1959.2. Gerald, P. S. Blood, 1958, 13, 936.3. Pisciotta, A. V., Ebbe, S. N., Hinz, J. E. J. Lab. clin. Med. 1959, 54, 73.4. Lie-Injo Luan Eng, Sadono. Brit. med. J. 1958, i, 1461.5. Schneider, R. G., Haggard, M. E. Nature, Lond. 1958, 182, 322.6. Vella, F., Wells, R. H. C., Ager, J. A. M., Lehmann, H. Brit. med. J.

1958, i, 752.7. Kunkel, H. G., Ceppelini, R., Dunn, L. C., Firsheim, L. Cited by

R. Ceppelini in Biochemistry of Human Genetics; p. 134. London,1959.

pathology, the administrative control of which will beby a council elected by the members of the faculty, thatadmission will be by an examination controlled by thefaculty with a generous provision for foundation member-ship, and that members of the faculty will be eligible forelection to fellowship of the Royal College in the sameway and by the same machinery as members of the

college. The proposed accommodation for administrativeand scientific purposes and the financial provisionsappear to be satisfactory.These proposals appear to me to be generous and to

indicate a sincere and genuine desire on the part of theRoyal College of Physicians to receive into their sodalitythe general body of pathologists in this country. It isfor you to decide whether you wish to be associated withan ancient and honourable college with great prestigeand influence, whose examinations are likely to receiveimmediate recognition, or whether you prefer to standalone either to establish an independent College of

Pathologists, with full realisation of the delays that thiswill involve both in setting up an examination and inobtaining recognition for it, or to refrain from action

altogether, indifferent to the challenge of the future.

NOMENCLATURE OF

ABNORMAL HÆMOGLOBINS

AT the eighth International Congress of Hxmatology,held in Tokyo last month, 44 members met to discuss thenomenclature of the human hxmoglobins. This field is

expanding so rapidly that it is not possible even at aninternational congress to obtain a full representation of alldisciplines and groups of workers. The absence of severaldistinguished investigators in this field was acutely felt.Nevertheless the congress was considered the best

possible occasion for such a gathering. The followingrecommendations are being issued so that those not

present will be able to criticise them in public:1. The recommendations on nomenclature made at the

Symposium on Abnormal Haemoglobins in Istanbul in 1958,and published in 1959,1 are endorsed and the letters A-N

(with the exception of B), and S are recognised as naminghaemoglobins as there defined.

2. The description of the variants of haemoglobin M asMB, MM, Ms (from Boston, Milwaukee, and Saskatoon

respectively) is accepted,2 3 and it is suggested that new hxmo-globins M are described with fully subscripted names untilthey have been shown to differ from these three when theyshould be given subscript initials (MIwate, possibly later MI).

3. The letters 0, P, and Q are being allotted to the hxmo-globins described under these letters.4-6

4. Until the next International Congress the letters R-Z(excepting S) should not be allotted to new abnormal hxmo-globins but these should be given names of localities. Itshould be left to the individual workers to choose the most

meaningful name from the origin of the propositus, or thelaboratory, hospital, town, or district where the haemoglobinwas found. A new name should not be allotted in this way un-less it has been ascertained that the haemoglobin to be namedis different from all those adequately described in the literature.

5. Of the two designations of the haemoglobin A2 variant:A2 and B2,’ the first is found more acceptable. If a third variantshould be found it should be named Az and not C2-