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finding of skin pallor, a normal pulse-rate (unusual inother acute abdominal diseases), paresis of wrist and

finger extensors, and a blue-black line on the gums (thislast sign is absent in the edentulous and in those who keeptheir teeth clean). The diagnosis may be confirmed byfinding in the blood hypochromic anaemia, stippled redcells, and increased serum-bilirubin. Urinary excretionof lead is increased, and porphyrinuria and coproporphy-rinuria may be present.When plumbism is borne in mind, its diagnosis is not

difficult. But the possibility may be forgotten unless thehistory is carefully investigated. As Mann shows, it isnot enough to record a patient’s occupation as " labourer ":he may work in a lead foundry; he may be a shipbreaker’sburner; he may work in an accumulator shop. One manwhose occupation was shown as lorry-driver had turnedfrom work with red lead only three days before his(unnecessary) operation. Another had taken lead and

opium pills for diarrhoea over a long period.Sometimes the source of lead poisoning is more occult.

Whitehead and Prior 6 recorded a case where the sourcewas an antique lead-glazed bowl used for making home-made wine (lead-glazed pottery is still used quite exten-sively in Central Europe for cooking 7). If lead-poisoningis not always borne in mind this is largely because itsincidence has been greatly reduced and most cliniciansnow see only occasional cases. It is noteworthy that inMann’s series one doctor practising in an area whichincludes a shipbreaking yard referred 9 cases to hospitalall correctly diagnosed.

TODD’S PALSY

How activity in the nervous system stops is just asinteresting a question as how it starts. Sherrington andPavlov both recognised the importance of inhibition. Asimilar problem can be posed about epilepsy: what causesthe convulsion to cease ? Nowadays, an explanation mightinvolve some Renshaw-cell system or its equivalent in thehigher reaches of the nervous system, re-establishing acontrol temporarily lost. Fifty years ago, however, onepopular explanation was that of cell exhaustion.The nerve-cells concerned in the epileptic discharge

were thought to be exhausted by their abnormal activity;the fit consequently ceased and sometimes a transientparalysis of the affected part followed. In 1854 Todd 8

described cases of postepileptic hemiplegia in whichparalysis lasted " for a few minutes or hours to three orfour days or even longer ". This condition earned thetitle Todd’s palsy-applied to any variety of local post-ictal paralysis, though in fact Bravais 9 seems to have beenthe first to describe the phenomenon.From Todd’s original description, it seems probable

that he did not clearly identify those cases in which a fitushered in some cerebrovascular accident, so that some ofhis long-lasting supposedly postepileptic paralyses wereprobably due to actual cell damage. But some otherexplanation is needed for the paralysis which lasts forminutes or hours and then recovers completely. The ideaof cell exhaustion was supported by Hughlings Jackson, 10who suggested that paralysis appeared first in that partwhich had been most actively engaged in the fit. Gowers"6. Whitehead, T. P., Prior, A. P. Lancet, 1960, ii, 1343.7. Beritić, T., Stahuljak, D. ibid. 1961, i, 669.8. Todd, R. B. Clinical Lectures on Paralysis. London, 1854.9. Bravais, L. P. Thèse de Paris, 1827.

10. Jackson, J. H. Brit. med. J. 1890, i, 703.11. Gowers, W. R. Epilepsy and Other Convulsive Diseases. London, 1881.

disagreed both with this observation and with the explana-tion. He favoured some positive inhibitory mechanismand pointed to the similarity of the occasional case ofepilepsy in which the whole fit was inhibitory or akinetic.

Efron 12 returns to this problem and discusses it in rela-tion to a case of post-traumatic epilepsy where arrest ofseizures by the application of strong sensory stimuliincreased the severity of post-ictal palsy. He suggests thatthe same mechanism is responsible both for " inhibitory "epilepsy and for post-ictal inhibition resulting in palsy.From an analysis of the clinical facts, he argues convin-cingly that the segregation of these two forms of paralysisassociated with epilepsy is artificial. As a tentativeexplanation for both, he puts forward a mechanism ofhyperpolarisation. Although there is as yet little positiveevidence to support it, it is on the whole compatible withwhat we know of the physiology of discharging neurones.The explanation of what we mean by both " exhaustion "and " inhibition " may find common ground in

hyperpolarisation.

INTERNATIONAL IMMUNISATION REQUIREMENTSMANY medical officers of health are getting rather

weary of telephone calls from intending travellers (ortheir family doctors) seeking guidance on immunisation.The travel agents can (or should) advise on the com-pulsory requirements of foreign countries and they issueblank international certificates; but they do not alwayskeep abreast of changes in the regulations, especiallywhen this country earns unexpected ill fame as a potentialsource of smallpox; perhaps the surest way of obtainingup-to-date information is to apply to the consulate of thecountry to be visited. That the international certificatemust bear the stamp of the local health authority is anuisance both for the vaccinator and for the health

department, but recent happenings at our airports con-firm that a signature alone is not much guarantee of

anything. The cautious traveller will want to know whatdiseases other than smallpox, cholera, and yellow feverhe risks during or at the end of his journey, and whetherthese are preventable. Whatever his destination, it willdo no harm if he is immunised against the enteric feversand poliomyelitis, but it is asking a lot of any healthdepartment that it should know off-hand whether typhusor plague should be added to the catalogue. There is, nodoubt, a file in the cupboard containing a heap of ratherdog-eared letters on these subjects from the Ministry ofHealth; but, even supposing that the out-of-date ones havebeen removed, they are inconvenient for rapid reference.

In a few well-printed pages the new edition of theofficial American booklet on the subject 13 answers almostall these questions, and we recommend it heartily as acompanion to our own Army Memorandum on Immuno-logical Procedures.14 The core of the book is a list of thecountries of the world, for each of which is given a listof the immunisation procedures which are compulsoryand another of the additional ones recommended by theU.S. Public Health Service. There is a full account ofthe international certificates of vaccination (which aremore complex than they seem) and some matter of morelocal interest on the prevention of the spread of yellow12. Efron, R. Brain, 1961, 84, 381.13. Immunisation Information for International Travel. U.S. Public Health

Service Publication no. 384, 1961. Obtainable from Superintendent ofDocuments, Government Printing Office, Washington, 25, D.C.25 cents.

14. Memorandum on Immunological Procedures. H.M. Stationery Office,1961. See Lancet, 1961, ii, 1262.

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fever from Central America. Our Ministry of Healthwould be doing a useful service if it prepared a similardocument, oriented to our domestic needs, and issued itwith the Prescriber’s Journal.

TREATMENT OF BACILLARY DYSENTERY

EVEN in Great Britain, where the more severe forms ofthe disease are uncommon, acute bacillary dysenterydeserves active treatment. Sulphonamides and someantibiotics will quickly relieve the distressing symptoms,will save some lives among the very young and very old,and will shorten the period during which the patient isa source of infection to others. The quicker the treatmentis begun the better; but the choice of the drug, among somany which are effective, is not always easy. One of ourmost valuable allies in the late war was sulphaguanidine,which not only saved many lives but won battles. This

drug has now given way to more active compounds of thesame class; and, without much justification, there has beena tendency to revert to those which are absorbed moreeasily. Streptomycin by mouth is at least as efficacious asthese, and in combination with one or more of the sul-phonamides has become a household remedy for diarrhoeain some parts of the tropics. Later studies have suggestedthat some of the broad-spectrum antibiotics are even moreeffective. Bibile et al.1 in Ceylon confirm that tetracyclinedispels the patient’s symptoms and frees him from infec-tion more quickly than do sulphadimidine, sulpha-methoxypyridiazine, or ’ Streptotriad ’ (a combination ofsulphadiazine, sulphamerazine, sulphathiazole, and strep-tomycin) but that between these last three there is nothingto choose. Tetracycline is not cheap, and these workerssuggest that a long-acting sulphonamide should be usedfirst and that, if clinical cure does not follow almost atonce, tetracycline should be used instead.

In time, no doubt, the ingenious pharmacologists willfabricate even more effective remedies for bacillarydysentery; but published reports show that it is becomingmore and more difficult to prove that one treatment isbetter than another. Some patients with this disease arecured very quickly by non-specific treatment or with notreatment at all. It is no longer easy to collect enoughcomparable cases. In this country the admission to hos-

pital of any but the most severely ill is discouraged-andrightly so-and where the disease is endemic and abundant,hospitals, laboratories, and doctors are scarce. Ceylon isan exception, but there are reasons for hoping that there,too, it will soon be difficult to find enough patients withthis disease. When four methods of treatment, each

applied to a group of 20 patients, are to be compared, thedifferences in the results must be considerable if they areto convince even the most credulous statistician. Future

comparisons will be between drugs all of which givesatisfactory results in nine patients out of ten. Those whomake these comparisons should come to some agreementon the criteria of success: here W.H.O. might help. Tothe doctor at the beside the duration of fever and/or ofdiarrhoea is the most valuable test of cure: to the hygienistit is the absence of the causal organism from the faeces.The latter is the easier to measure precisely, but its

importance may be overvalued: experience supportsRoss’s suggestion that at any rate in Sonne dysentery thesymptomless excretor seldom spreads infection.2 Occasion-ally children who have recovered from Sonne dysentery1. Bibile, S. W., Balasubramaniam, K., Cooray, M. P. M., Gulasekaram, J.

J. trop. Med. Hyg. 1961, 64, 300.2. Ross, A. I. Mon. Bull. Minist. Hlth Lab. Serv. 1955, 14, 16.

continue to excrete the organism for weeks or even monthsdespite intensive treatment with drugs. This feature, inwhich drug resistance seems to play no part, seems to bebecoming commoner, and it suggests the establishment ofa symbiotic relationship which will complicate the inter-pretation of the tests of bacterial cure. As far as we know,such long-continued carriage of the causal organism israre after infection with the other shigellas, and there areother reasons for doubting whether all the facts derivedfrom one can be applied to the others. Sonne dysenteryis usually but not always milder than infections due toSh. flexneri or shigz. At any rate, in Great Britain, thedisease has a natural history all of its own. Like otherintestinal infections it used to flourish in the summer andautumn, but in the past ten years it has become a diseaseof the winter and spring. The organism is surprisinglyresistant to an unfriendly environment. It can be spreadby food and drink, but other routes play a major part inits spread. As a nation we have been martyrs to thisinfection since the war, but no country has a better supplyof potable water. Where Sonne and Flexner dysenteryoccur together (as in Cyprus) no obvious differencebetween them can be detected, but this does not mean thatSonne dysentery in Aberdeen will always behave likeFlexner dysentery in Colombo. Bibile’s paper relates toFlexner dysentery only, and is the more valuable for thisreason.

Those who describe therapeutic trials do not always tellus enough about the relative costs : generally speaking, weprefer the cheapest. Bibile’s recommendation of a long-acting sulphonamide with tetracycline as a standby seemsrational. Tests of cure involve matters of conscience aswell as of fact. As a rule the patient who is fit to leave hisbed is fit to leave the hospital, but we should have moreexact knowledge of the part played by the convalescent inspreading infection. Few except the bacteriologists worrymuch about the flora of their own bowels.

AEROSOLS AND PNEUMONIA

THE inhalation of aerosols containing spasmolytic drugsfor the relief of bronchospasm has become establishedpractice. Attempts to thin tenacious bronchial secretionswith proteolytic enzymes similarly given have not so farproved entirely satisfactory; c.nd in respiratory infectionsantibiotics are now seldom given in this way. Grant’ 1

concluded that this method " has not proved a satisfactorytechnique for the administration of antibiotics even wheninfection is apparently localised to the bronchial mucosa ".A recent report from the United States 2 describes an

attempt to combine an aerosol proteolytic enzyme, pan-creatic dornase, with an aerosol antibiotic. These twosubstances were given via an intermittent positive-pressurerespirator to 30 patients with pneumonias of various

types who were already receiving systemic antibiotics.15, mostly elderly men, had staphylococcal pneumonia,and in 6 cases this had followed operation. Paine et a1.2found that aerosols used in this way were a useful adjunctand helped appreciably in thinning tenacious infectedsputum. No patient died in this series and the techniquewas of particular benefit to old and weak patients. Paineet al. conclude that "in a patient seriously ill with

pneumonia, the combined use of systemic antibiotics withaerosols of pancreatic dornase and antibiotics is probablythe most effective method

"

1. Grant, I. W. B. Practitioner, 1958, 181, 703.2. Paine, J. R., Spier, R., Witebsky, E. J. Amer. med. Ass. 1961, 178, 878.