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on the penetration of penicillin into the normal cerebro-spinal fluid formed part of the experimental evidence onwhich our arguments were based. Merely for reasons ofconvenience and accessibility, the intrathecal space waschosen as a representative of those tissue-spaces in

general which might ordinarily not be reached by peni-cillin administered in moderate doses. The fact that itwas only after massive dosage that penicillin could

penetrate into the cerebrospinal fluid was therefore

brought forward to support the case for such dosagein all stages of syphilis, " since the organisms are to bedestroyed not merely in the circulating blood but alsoin all manner of extravascular sites to which they mayhave gained access."

Department of Pharmacology, Oxford. E. M. LOURIE.

TREATMENT OF ACCIDENTAL ARSENICALPOISONING WITH DIMERCAPROL

SIR,—Dimercaprol (BAL) now has an established placein the treatment of toxicity from parenterally adminis-tered arsenical compounds. The following account ofthe use of the drug to treat acute arsenical poisoning dueto the swallowing of arsenical cattle-dip may be of interest.A party of 13 African women was working by the side of a

stream, making bricks to be used in building a tank fordipping cattle. To make the brick clay into the properconsistence for placing in the brick moulds, water was beingcarried up from the stream in a number of receptacles-mostly used cattle-dip drums of about 4-gallon capacity.At about 10 A.M. it was getting hot, and one of the women

was sent to the stream to fetch water for drinking. For thisshe took a dip drum which was empty but had not beenwashed and scrubbed. She washed the drum in the streamin a perfunetory-way and brought the water to the brick-making site, where all the women slaked their thirst.Within a few minutes the whole party was vomiting, and

within half an hour 2 of the women were collapsed. Theyrealised that they had been poisoned and sent for help.They were many miles from the nearest telephone and about40 miles from the hospital, which they did not reach until 5 P.M.On admission 11 of the women, though still vomiting and

complaining of abdominal pain, were able to walk and to

give a clear history, and were obviously recovering. In hospitaltheir vomiting soon grew less, and they continued to improve.The remaining 2, however, were completely collapsed. It was

learnt that they were the last to drink from the drum, andpresumably they drank the dregs. Each complained ofnausea and vomiting, violent abdominal cramps, pains in thelegs. and precordial pain. They cried out with each spasm ofcolic; so, in view of the usual African stoicism, the pain musthave been very severe indeed. Their skin was cold and grey ;their conjunctive were suffused and their tongues dry ; andtheir pulses were feeble.

It was decided that in view of the delay since the arsenichad been consumed there was little point in washing out thestomach ; detoxication was the urgent need. The patientswere kept warm and nikethamide was given subcutaneously.Dimercaprol was given in 2 ml. doses intramuscularly threetimes at four-hourly intervals-i.e., at 5.30 and 9.30 P.M. andat 1.30 A.M.Next morning the general condition of both patients was

much improved ; they were no longer collapsed, vomitinghad ceased, and the abdominal pains were only occasionaland fleeting. Twenty-four hours afterwards they were fullyrecovered and were out of bed ; and the next day theyannounced that they were well and insisted on leaving hospital.The drum from which the women had drunk was

brought in for inspection. It was clearly marked " cattle-dip." The liquid in the bottom was dark brown andhad the characteristic odour of cattle-dip.

Cattle-dip consists of a solution or emulsion of arseniteof soda to which has been added some substance such asaloes to prevent the cattle drinking it. In concentratedsolution in the drum the sodium-arsenite content isabout 80%-or 64% expressed as arsenic trioxide. Fordipping cattle to kill ticks, the concentrated solution isdiluted 1 in 400 so that the final solution contains theequivalent of 0.16% arsenic trioxide. There seems little

doubt that the two women who were seriously ill musthave ingested a very large dose of arsenic.Where there is any delay between the accidental

swallowing of arsenic and the institution of first-aidmeasures, such as washing out the stomach, dimercaprolwould seem to be a very useful drug for countering theeffect of the absorbed arsenic, giving results no’ lessdramatic than in poisoning arising after parenteraladministration of the organic arsenicals.

Concession, Southern Rhodesia. D. A. W. RITTEY.

LEAD NIPPLE-SHIELDS

SIR,—I have read with interest and great care yourleading article last week and the article by Dr. Gordonand Mr. Whitehead. The embargo by the Ministry ofHealth on the sale of lead nipple-shields must be a sourceof satisfaction to you, since you recommend theirabolition. Has it occurred to you that a valuable aidto breast-feeding has thus been abolished, and is thisalso a source of satisfaction ?

In certain cases lead nipple-shields are a unique aidto breast-feeding ; they have enabled me to feed eachof three babies for a normal period of nine months,when all other remedies had failed to relieve severelycracked nipples. For a fourth child, the Ministry’sembargo will compel me to wean at a few days old.

I see no justification for such action in Dr. Gordon’sarticle. In the case cited he expressly states that themother used lead shields continuously without washingher nipples before each feed. This only justifies a warningthat scrupulous cleanliness is necessary when using leadshields. The possibility of lead deposits being absorbedand then excreted with the milk is a mere suggestionwhich, Dr. Gordon states, he has never investigated.The letter in your columns from Dr. Mackay and

Dr. Hunter yields even less precise evidence. Theyassert that the use of lead shields necessitates a meal oflead for the suckling child. Have they never heard ofthe simple precaution of washing ? The suggestion thatplastic shields can replace lead ones is frivolous ; no-onewho has observed the effect of lead shields with intelli-gence can doubt that the deposits from the lead are avaluable part of their healing power.

" The facts " of this controversy are more teasing andelusive than you or your correspondents indicate. Mayone hope that the humility which should inform allresearch may lead you to investigate the matter further ?

Pilton, Barnstaple, Devon. JOAN S. BLACKSELL.

Public Health

Setback in Scottish Campaign Against DiphtheriaIN Scotland the campaign for protection against

diphtheria has suffered a serious setback. The Octobernumber of the Health Bulletin issued by the Departmentof Health contains an analysis showing that at the endof 1948 51-4% of preschool children and 73-4% ofschool-children were protected. (About 12-13 % ofbabies in the preschool group are too young for inocula-tion.) Both these percentages are higher than a yearbefore ; but in the second half of 1948 : (1) the numberof preschool children inoculated fell somewhat ; (2) thenumber of school-children inoculated fell dramaticallyto a much lower level than in anv six months since thecampaign started ; and (3) the number of reinforcingdoses given fell to just over half the number in the

previous six months.Nothing, says the bulletin, has happened to discredit

immunisation, and the disease is not yet so rare as

to delude the public into believing that protection isunnecessary ; moreover, there has been no great changein central propaganda.

During 1948 there was increasing shortage of local-authority personnel—’’ a shortage which, in the case ofmedical staff, was intensified by a number of healthofficers obtaining appointments under regional hospital

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boards." That this shortage largely explains the declinein the number of inoculations has been corroborated bycomparing local figures for inoculations with those forstaff.

*’ The highly significant association between dwindlingnumbers of inoculations and increasing shortages of assistantmedical officers of health implies either that the two itemsare causally related or that both are due to some commoncause ; but the causes of the shortage of public-healthdoctors are well enough known-depletion of existingcomplements by retirals and by doctors quitting the fieldof public health, and difficulty in obtaining doctors withqualifications to fill these vacancies. Hence it must beconcluded that an important cause of the decline in thenumber of inoculations is shortage of public-health doctors."

During 1948 diphtheria cases in Scotland numbered723-the lowest total ever recorded. The number ofdeaths was 31-just under 6% of the number in 1941.

Higher Mortality from Rheumatic FeverEarlier this year we heard of an impression among

pathologists that the number of necropsies on cases ofacute rheumatic fever was increasing. We consultedthe General Register Office, which has kindly suppliedthe following figures for deaths from rheumatic feverin England and Wales during the years 1946-48 :

For the forty years ending 1892 the mean death-ratefrom rheumatic fever was about 87 per 1,000,000-seventimes that of 1942. In 1901 the crude death-rate per1,000,000 was 67, and by 1913 it had fallen to 48.1Since 1925 the rate has fallen more or less steadily.The following tables give the figures for deaths in eachyear from 1928 to 1938,2 and from 1938 to 1948 3 :

1. Glover, J. A. Lancet, 1943, ii, 51.2. Registrar-General’s Statistical Review of England and Wales for

the Year 1938. Tables. Part I. Medical. H.M. StationeryOffice, 1940.

3. The figures for the years 1938-47 are taken from the Registrar-General’s Statistical Review for 1947. The criteria differslightly from those used in compiling the figures for 1928-38 ;and this accounts for the difference between the two tables inthe number of deaths in 1938.

It will be seen from these figures (which excludenon-civilian males from Sept. 3, 1939, and non-civilianfemales from June 1, 1941) that though the annual totalof deaths has risen during the past two years, itremains below that for 1945.

During the late war, Glover,1 who drew attention tothe parallelism between the death-rates from scarletfever and rheumatic fever, suggested that the continuingdecline in deaths from rheumatic fever might be due lessto improved environmental conditions than to a changedrelation between man and Streptococcus pyogenes. Itwill be recalled that by regulations 4 made two years agoacute rheumatism is notifiable in Lindsey (Lincolnshire)and in Bristol, Grimsby, Lincoln, and Sheffield ; andperhaps the epidemiological study which these regulationshave made possible will help to explain the presentsetback. Though more sustained, this is not so greatas that suffered between 1942 and 1943 ; and it seemspossible that, as in 1944, the interrupted decline maybe resumed.

PoliomyelitisDuring the week ended Oct. 1 notifications in England

and Wales were : poliomyelitis 331 (268), polio-encephalitis 26 (27). The numbers for the previousweek are shown in parentheses. As the accompanyingfigure shows, these are the highest weekly totals this

Notifications of poliomyelitis and- polioencephalitis.

year. In 1947 the totals for the corresponding weekwere poliomyelitis 441, polioencephalitis 32.

Multiple cases (poliomyelitis and polioencephalitistogether) were reported from the following counties :London 44 (48), Bedford 5 (1), Berkshire 5 (3), Bucking-ham 2 (1), Chester 4 (7), Cornwall 8 (8), Dorset 5 (4),Durham 3 (1), Essex 26 (17), Gloucester 17 (0), Hertford12 (7), Kent 19 (18), Lancaster 41 (24), Leicester 2 (5),Norfolk 4 (2), Northampton 4 (4), Northumberland 6 (13),Nottingham 9 (9), Somerset 6 (7), Southampton 7 (8),Suffolk, East 2 (5), Surrey 9 (11), Sussex, East 5 (1),Warwick 13 (8), Wiltshire 8 (9), Yorks, East Riding3 (1), Yorks, North Riding 2 (1), Yorks, West Riding38 (19), Glamorgan 6 (3), Monmouth 2 (0).

Insurance Against TuberculosisWhether tuberculosis in nurses and other health

workers should be a " prescribed disease " under theNational Insurance (Industrial Injuries) Act is beingconsidered by the industrial diseases subcommittee ofthe Industrial Injuries Advisory Council. Persons andbodies interested in this question are invited to submitwritten evidence, not later than Dec. 1, to the council’ssecretary, Mr. F. K. Forrester, Ministry of NationalInsurance, 6, Curzon Street, London, W.1, from whoman explanatory memorandum may be obtained.

4. See Lancet, 1947, ii, 394, 409.