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Denny-Brown and Porter were able to maintain improve-ment until it was clear that the treatment would notbenefit the patient any more. By that time 4 of the5 could fend for themselves; and even the 5th patient,who had shown considerable mental and physicaldeterioration before having dimercaprol, had madesome improvement. A side observation of some interestis that in 2 patients the Kayser-Fleischer cornea! rings(present in all 5) lost much of their brownish colour.As Newell et al.5 have shown that dimercaprol removesexperimentally introduced intra-ocular copper, thisobservation lends support to the view that Kayser-Fleischer rings are, partly at least, attributable to

copper deposited in the cornea.Dimercaprol was given intramuscularly as a 10%

solution in peanut oil, care being taken to avoid sub-cutaneous deposition because this gives rise to painfullumps. Injections approximated to 2-5 mg. per kg.of body-weight, but they were reduced when necessaryto avoid unpleasant side-effects, which at this strengthincluded transient nausea and vomiting, dizziness, andblurring of vision. No serious toxic effects were

encountered save in 1 patient when a single injection of7 mg. per kg. body-weight evoked a hsematemesis.In the earlier months of the trial, injections of dimer-caprol were given every four hours for twenty-four hours,repeated twice at five-day intervals ; but later it wasfound more convenient to give twice-daily injections of1-0-1-5 ml. for ten to twelve days. The recommendationis that such a course be repeated monthly until a steadyclinical status is reached, after which a maintenancecourse of a similar order should be given every secondmonth.

Clinical evidence of liver damage was apparent in

only 1 patient before dimercaprol was given, and liver-function tests showed only mild hepatic insufficiencyin the other 4. A close watch was kept for indica-tions of further hepatic damage after treatment hadstarted, but such damage was never apparent. Never-theless all 5 patients showed a resting urinary copperoutput ranging from 207 to 713 .g. per twenty-fourhours, as compared with the normal, levels ranging fromzero to 14-7 ug. quoted by Porter,6 The effect of four-

hourly injections of dimercaprol in a strength of 7 mg.per kg. body-weight was to raise the resting output ofcopper in the urine some 2-7 times in the first twenty-four hours, though it afterwards fell rapidly and returnedto the resting level on the third or fourth day. Itwas estimated that in this way during one three-daycourse about 3-4 mg. of copper was mobilised : thiswould be about half the copper-content of a normalliver but is only about 5% of the copper-content of theliver in hepatolenticular degeneration, in which condi-tion both liver and brain contain excessive amounts of themetal. As the bile is normally the chief route of copperexcretion Denny-Brown and Porter carefully estimatedthe copper-content of the bile in 3 patients- expectingto find the output by that route loweied by the hepaticdamage, but the biliary copper-content turned out to benormal in all 3. They think that the increased urinaryoutput of copper must be attributable to overabsorptionof the metal, which results in high serum-copper Isvels,a,s found by Glazebrook 8 and Cumings,3 with retentionin the tissues and overflow over a renal threshold. LikeCumings they found that dimercaprol had no effecton the amino-aciduria which was noted in all their

patients and which ordinarily fluctuated a good deal.Thus there is now good evidence that the neuro-

logical symptoms of hepatolenticular degeneration are

related to the abnormal accumulation of copper com-

5. Newell, F. W., Cooper, J. A. D., Farmer, C. J. Amer. J. Ophthal.1949, 32, 161.

6. Porter, H. Arch. Biochem. Biophys. 1951, 31, 262.7. See Lancet, 1951, i, 1404.8. Glazebrook, A. J. Edinb. med. J. 1945, 52, 83.

pounds in the brain. Denny-Brown and Porter haveshown that such symptoms as tremor and rigidity,even when of long duration, lessen considerably whencopper is repeatedly mobilised with dimercaprol, and

they very reasonably suggest that the earlier such treat-ment is begun the more complete recovery will be. Yetit remains to be seen whether earlier cases will proveequally. amenable to dimercaprol ; for in treating his4 patients Cumings saw no substantial improvement inthe 2 who neither had signs of liver damage nor had botha raised excretion of copper and a raised excretion ofamino-acid nitrogen in the urine. Further trials with

younger patients and earlier cases are now required.

1. See Lancet, 1950, i, 553.2. Burgess, J. F. Canad. med. Ass. J. 1951, 65, 567.

POISONING FROM MATCHES

WHITE or yellow phosphorus has not been used in themanufacture of matches since the Berne Convention of1906. It has been replaced by phosphorus sesquisulphide(P4S3) in the heads of the " strike anywhere " matches,and by potassium chlorate and other ingredients insafety-match heads. Red or amorphous phosphorus ispresent in the striking surface of safety-match bQxes,lBoth red phosphorus and phosphorus sesquisulphide arethought to be relatively non-toxic. Recent evidence putforward by Burgess 2 suggests, however, that phosphorussesquisulphide may cause not only dermatitis of the faceand eyelids but also mild systemic phosphorus poisoning.He describes the cases of two women, both of whom

used the friction or " strike anywhere " matches to lightcigarettes. One, aged 61 years, had severe dermatitisof the eyelids and face in 1933, lasting about a year.Her teeth became very loose, and though there was nocaries they were all extracted. The skin lesion graduallysubsided, but there were occasional recrudescences inthe succeeding years. In 1941, she began to get attacks,increasing in severity and frequency, of oedematousdermatitis on the original sites. These attacks wereaccompanied by prostration, severe vertigo, loss of

appetite, and nausea and vomiting. Investigations overthe years failed to reveal the cause of the condition untila chance remark led her medical adviser to suspect thatfriction or " strike anywhere " matches might be-impli-cated. A patch-test with a friction match gave a delayedpositive reaction, and further tests with a safety-match andthe friction side of a safety-match box were also positivein 48 hours. Since the patient gave up using matches thetoxic symptoms and the skin lesions have cleared upcompletely. The second case was a 31-year-old womanwho had had recurring cedematous dermatitis about botheyes and cheeks for 9 months. For the previous 2 yearsthe upper and lower teeth had been somewhat loose, andshe had had transitory attacks of dizziness. Patch-testswith friction matches were positive within 20 hours, andthere were also slight positive reactions from a safety-match tip and the friction surface of a safety-match box.The symptoms and signs promptly cleared up when thepatient gave up using matches. Her dentist reported thather teeth have improved, though it is not stated whetherthe loose teeth have become firm again.

Burgess says that though no similar cases have beendescribed they may not be uncommon. The skin mani- festations may be explained by sensitivity to phosphorussesquisulphide and its combustion products. The causes Iof the systemic toxic symptoms and the dental changes iare more difficult to assess. These bear some resemblanceto mild industrial phosphorus poisoning. It is possible, ;but unlikely, that unoxidised atoms of phosphorus might v

be present in match combustion fume. Incomplete Ioxidation forms of phosphorus, such as the trioxide

’I(P4O6) and the pentoxide (P401o), or the phosphorussulphides, could through inhalation give rise to slow, r

mild phosphorus poisoning.

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It so happens that in the south of England the safety-match is largely used, whereas in the north and in

Scotland the red-headed " strike anywhere " match,

which contains phosphorus sesquisulphide, is more

popular. We know of a man who during the late warhad to make periodic trips from London to Edinburgh,and who developed codematous dermatitis of the faceand eyelids each time he went north. The trouble was

finally traced to the use of the " strike anywhere "matches which he bought in Edinburgh. It is not knownwhether loosening of the teeth is more prevalent amongsmokers in the north than it is in the south ; and thedental profession might regard this as a fruitful field toinvestigate in association with the dermatologists.

1. Maternity Benefit. H.M. Stationery Office, 1952. Pp. 39. 1s. 3d.

MATERNITY BENEFITS

WHEN funds are low, the State, like the privatecitizen, must take pains to lay out its cash to the bestadvantage. In 1950 Dr. Edith Summerskill, then Ministerof National Insurance, asked her advisory committeeto look into the question of maternity benefits and tosee whether, without adding at all to the present outlay,the money spent could be more equitably distributed.The committee have now reported.1Under the National Insurance Act. 1946, the maternity

grant was set at £4; women in gainful occupationsreceive a maternity allowance of 36s. a weekfor 13 weeks, beginning with the 6th week beforethe expected date of confinement; and, furthermore,those not eligible for the maternity allowance (becausethey are not in work) can claim an attendance allowanceof £1 a week for the 4 weeks following their confinement,towards the cost of domestic help. If the confinementis delayed the maternity allowance can be continued formore than 13 weeks, but the woman cannot draw thisallowance while she is working. By regulations, neithersickness nor unemployment benefit may be paid at thesame time as maternity allowance or attendance allow-ance, but either may be drawn instead, if of greateramount. Unmarried women are eligible for maternitybenefit, on their own insurance contributions, on thesame conditions as married women. A married womanin gainful occupation, however, is allowed to choosewhether to pay National Insurance contributions or notShe cannot have unemployment or sickness benefitunless she contributes, but at present she does get thematernity allowance—for which the only requirement isthat she should have been in work for 45 weeks of the

year preceding the 6th week before her expected confine-ment. The committee propose that in future maternityallowance shall be payable only to women who paycontributions; and that the same total sum (£23 8s.)should be paid at the rate of 26s. (instead of 36s.) fora period of 18 weeks, beginning from the 11th week beforethe expected date of confinement ; if the confinement islate, the time of benefit should be extended, as it is atpresent. During the year ending at the 13th weekbefore the expected confinement date the mother musthave paid 45 contributions (or been credited for weeksof unemployment or sickness ; but at least 26 contri-butions must have been paid). Sickness or unemploymentbenefit should not be payable at the same time as thematernity allowance, but (as at present) whichever isthe larger sum may be claimed. Women who havedependants should be allowed to claim dependencybenefit besides the maternity allowance.The committee were told by several witnesses that

the woman confined in hospital has fewer expenses thanthe woman confined at home ; and they have proposedchanges in the attendance allowance to straighten thisout. They propose that the present maternity grant of £4should be replaced by a new prenatal grant which"should be increased at the earliest opportunity to an

amount substantially in excess of the present sum of£4"; and they think the proposed changes in the

maternity allowance should release some money for thispurpose. They also propose that the present attendanceallowance of £1 a week for 4 weeks should be replacedby a new grant, to be called (most confusingly) thematernity grant, of £3 when the confinement is inhospital and £6 when the confinement is at home ; andwhen a woman is entitled to the new maternity allowanceshe should also be entitled to both the prenatal and thematernity grant, without further contributions. In allother cases either the woman or her husband must have

paid 26 contributions during the preceding year.These new provisions, if accapted, should mean a much

fairer distribution of available money.

1. Gray, S. J., Benson, J. A., Reifenstein, R. W., Spiro, H. M.,J. Amer. med. Ass. 1951, 147, 1529.

HORMONES IN PEPTIC ULCERATION

CoRTUESPONDENCE in this issue reminds us that noteveryone is agreed about the value of psychotherapy forpatients with peptic ulcers. On the other hand, everytextbook attests to the relation between such ulcers and

anxiety : and Gray and his associates now suggest thatthe " pituitary-adrenal axis " is involved in this relation-ship as in so many other of the body’s processes. Theseworkers have treated six normal subjects with A.C.T.H.and with cortisone and have followed indices of gastricactivity, such as the acid and pepsin secretion into thestomach and the uropepsin excretion in the urine. In

every instance treatment increased these indices to levels

usually associated with an active duodenal ulcer ; theeffects were greatest after 7-14 days of continuous

therapy. In one patient with a known gastric ulcer,administration of A.c.T.H. produced signs of impendingperforation and pronounced increase in secretion of

pepsin. In another patient treated with A.C.T.H. uro-pepsin excretion rose to unusually high levels : this

patient had a massive and fatal gastric haemorrhage andduodenal perforations. Gray and his colleagues concludethat chronic emotional and physical stress may betransmitted to the stomach by a hormonal mechanism.

This work may come as something of a surprise tothose who have regarded the vagus nerve as the chiefpathway for impulses from the mind to the stomach.Since the days when Beaumont patiently observed theemotional paling and flushing of the gastric mucosa inthe temperamental Alexis St. Martin, there has been

repeated experimental proof that the emotions can

rapidly influence the human stomach ; and this suggestsa nervous mechanism. Furthermore, experimental vagalstimulation produces increased gastric motility and

secretion-changes which are found when an active ulceris present. Indeed, the vagus nerve has often beenresected as a remedy for peptic ulceration ; and this

operation has had its measure of success. No doubt

supporters of the hormone hypothesis of ulcer productionwill say that the operation also gives the patient physicaland mental rest- during recovery and convalescence.Exponents of the vagus-nerve theory may then retortthat ulcer patients do not have moon faces, as one wouldexpect if their malady was due to constant over-

production of cortical hormones. Probably the truth isthat both mechanisms are active, but neither is the

primary cause of the ulceration. It would be interestingto know how commonly peptic ulcers occur in patientswith Addison’s disease or Simmonds’s disease. At leastit is clear, liowever, that the development of pepticulceration and its complications is a hazard in adrenalcortical therapy ; and the presence of anuleer may be acontra-indication to such treatment.

The EAltI, OF LIMERICK has been appointed chairmanof the Medical Research Council in succession to thelate Lord Addison.