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even the Times has commented on the apparent hap-hazard appointment of consultants ; there is no doubtthat an inadequate number of consultant posts is beingmade. Here the interests of the Treasury and of manyestablished consultants coincide, though for differentreasons : the Treasury must cut the cost, and theestablished consultant does not want more competition.Furthermore, the Ministry of Health has not beenoveractive in trying to secure an agreed basis for theestablishment of consultants.To the Spens Committee the registrar was a trainee

specialist ; but now the name has been changed andwith it the status. A registrar can be employed for allmanner of purposes : a trainee specialist cannot be socynically used. This twisting of nomenclature has alsotaken place with the compound term " consultantsand specialists " ; the specialist half has been quietlvdropped. The average trained man does not expectconsultant status at the age of 32, but he does expectspecialist status.There is no hope of obtaining agreement on consultant

establishments until there is agreement on the amountof work and responsibility the average consultant shouldtake and on the amount of junior help he should have.Consultant establishments must be based on the unitof a consultant with one houseman. (I include in theterm " housemen " house officers and junior registrars,and in the term " registrars " registrars and senior

registrars.} The establishment of registrars should bedecided on a regional basis, and should depend on thenumber of consultant posts likely to be vacant in theregion during the next five years. Allowance for wastageshould not exceed 10 % over three years for senior regis-trars, and 10% over two years for registrars. In non-

teaching, but not in teaching, hospitals a consultant witha registrar would be able to manage a few additional beds.Such a scheme would ensure proper distribution of

consultants, and would give scope to the large number oftrained men now out of work or labouring under thethreat of dismissal.

Eiaov."SUFFOCATION" IN INFANCY

SiR,—With the report and the leading article in yourissue last week, the " suffocated " infant is in the medicalnews again and one’s years-old doubts and queries about,it, come out for spring-cleaning. Bacteriology and

histology may be completely unconvincing as to thecause of death. Can spasmophilia, due to altered

biochemistry, play the trigger part in some cases ? ‘?Dr. F. B. Smith found palpably soft skull-bones in

about one-third of his series. The paediatricians will

presumably agree that this proportion is far higher thanthat found in living infants of up to six months old, evenif palpable denting is ever " normal " at this age-whichI doubt. These infants are not seen by the paediatricians.They go straight from their-usually humble-cots orprams to the mortuary. But the degree of craniotabescan be an eye-opener to hospital residents invited thither ;either they have never seen it as students, or never sucha degree of it.What is the present consensus of psediatric opinion on

the signiticance of craniotabes at this age ? (I realisethat biochemical analysis in infants necessitates jugular,scalp-vein, or anterior-fontanelle puncture, and thatX rays are unhelpful in the first year.) A few years ago,I was told that the general opinion in Scotland was

judged to be that craniotabes was a sign of rickets ; buta few weeks ago a consultant psediatrician said that hewould not treat it so, without other evidence in support,and, further, that he was seeing very little rickets at hisclinics.Another point : if craniotabes is acceptable as evidence

of rickets. can the biochemical unset of rickets fand so

1. Times, Dec. 31, p. 5.

the risk of laryngospasm) be present without palpableskull softening ? If evidence is present of naturaldisease, capable of causing sudden or rapid death (andthe books say that laryngospasm can kill rapidly), thenmost convincing evidence would be needed to supportan opinion that death was unnatural. I can recall

carrying a coroner with me in recording a natural deathin an infant found with a pillow over its face.Mark you, Sir, I have found craniotabes in an infant

dying after a short illness in hospital, and then even moreconvincing meningococci in an early exudate on the brainwithin.

Department of Pathology,General Hospital, West Hartlepool.

R. T. COOKE.

DIPHTHERIA IMMUNISATION

SiR,—There are just two points in Miss Barr’s letterlast week which require comment.

Miss Barr fears that, with the decline in the incidenceof diphtheria infection, the Schick standard may proveinadequate to guarantee protection against the disease.I can only say that for many of the years during whichmy faith in the post-Schick negative result has beenbuilt up, adventitious stimuli, due to contact withinfection, have been almost lacking. My opinion wasnot lightly formed, and it has been tested repeatedlyby contact of my subjects with all grades of diphtheriainfection. Such cases of the disease as have occurredin my previously post-Schick negative children havenearly always been mild and non-paralytic. Thus I donot share Miss Barr’s apprehension on this point.

I should like to make it clear that when I referred tothe consideration of single-injection prophylaxis I meantexactly what I said. In the past, one-shot immunisationhad no more bitter opponent than myself, asmanufac-turers of such preparations may recollect. With theadvent of ever-improving prophylactics, I certainly donot despair of the elaboration of a single-injectionmethod which will control diphtheria adequately. Iwelcome the opportunity of boldly making a prophecythat this will happen.

Insistence on the necessity for an orthodox secondaryresponse may well be a definite bar (sorry-no pun !)to progress. There is more in this remark than meetsthe eye, but I am working at the problem at the presenttime, and can only say that my results, so far, are morethan encouraging.

Public Health Laboratory Service,134, Denmark Hill, London, S.E.5.

GUY BOUSFIELD.

PERMANENT WAVING AT HOME

SIR,-It is now widely recognised that the home

permanent-waving outfits which are on sale throughoutthe country depend for their action on ammonium

thioglycollate, which is applied for a variable time andthen neutralised by the application of potassium bromate.The bromate is normally supplied in powder form

which the user makes up into the neutralising solutionby mixing with water. The resulting solution is colourless,odourless, and almost tasteless; and it is, therefore, possiblethat in spite of warnings issued by the manufacturerssomeone may drink it. Accordingly, it may be useful tonote the instructions which have been issued in theUnited States for treatment of these cases :

If the neutraliser has been swallowed, an emetic should begiven : the stomach may be washed out. One level tea-

spoonful of sodium thiosulphate should be given after thepatient has been sick. Demulcent drinks, such as milk andthin gruel, may then be taken. If shock is a feature, treat thepatient for shock but avoid central nervous stimulants. Pain

may be relieved with morphine. Intravenous therapy withsodium thiosulphate has been employed, either by the injectionof 10-50 ml. of a 10% solution or by an intravenous dripusins 100-500 ml. of a 1% solution.

London, BY.1. R. M. B. MACKENNA.