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useful pointer 10 and is seen most often on the limbs (in97%) but also on the trunk (82%) and face (59%). In166 patients with Still’s disease, Isdale and Bywaters 10found that 85% of those with a rash had fever, whereasonly 34% of those without a rash were pyrexial. Inchildren with hyperpyrexia, a rash, and arthralgia Still’sdisease should be considered first, especially if lymph-adenopathy and splenomegaly are present. Even if onlyone joint is involved, hectic fever and the characteristicrash may be helpful in diagnosis 2 10 (although Griffinand his colleagues 11 did not find them so). In 5 of 50

patients with Still’s disease Calabro and Marchesano 2

found two daily peaks of fever, as sometimes seen ininfectious diseases such as kala-azar,12 gonococcal or

meningococcal endocarditis,13 14 and miliary tuberculosis. 15Accurate diagnosis may save a child from an unneces-

sary operation. When the disease begins in a single jointit may be mistaken for an early tuberculous infection -,and with high fever and severe polymorphonuclearleucocytosis, osteomyelitis or pyogenic arthritis may besuspected and the joint explored for pus. 7 patients inCalabro and Marchesano’s series had recurrent abdominal

pain, and 3 of these underwent laparotomy. Mesenteric

lymphadenopathy was found at operation and was thoughtto be the cause of pain.

Pyrexia does not necessarily carry a bad prognosis.Ansell and Bywaters,16 following up 43 probable cases ofStill’s disease, found that 23 could still be classified asStill’s disease 5 years later: 10 of these patients had abenign systemic illness with fever, 9 showed an oligo-arthritis, and 4 had a transient polyarthritis of less than3 months’ duration. The benign systemic illness, whichlasted 3-4 months and was self-limiting, was probably aforme fruste of Still’s disease.

THE HOSPITAL DOCTOR

THE discussions between the Minister of Health andmedical negotiators on the problems of doctors in the

hospital service are clearly infused with a will to reachaccord on conditions that will prove more tolerable for

junior staff. Most of the reasons for the underlying senseof crisis are painfully familiar. Briefly they are these: theUnited Kingdom has too few doctors and cannot hope torepair this deficiency for at least a decade; in the lowerechelons the hospitals rely heavily on overseas graduates,who might be better employed in their own countriesand whose number may dwindle; as has become increas-ingly evident, no natural law dictates that the number of" transient " junior staff shall suffice for all the profes-sional work not carried out by consultants, and theestablishment of the grade of assistant medical officer inpartial recognition of this has not proved a success; over-long hours of routine work and other disincentives temptgraduates to emigrate; and junior staff are now expressingtheir grievances with new coherence and force.The meetings have already resulted in action by the

Ministry (see p. 1153); and more will no doubt follow fromthe further discussions which are to range over almost

10. Isdale, I. C., Bywaters, E. G. L. Q. Jl Med. 1956, 25, 377.11. Griffin, P. P., Tachejian, M. O., Green, W. T. J. Am. med. Ass. 1963,

184, 23.12. Most, H., Lavietes, P. M. Medicine, Baltimore, 1947, 26, 221.13. Futcher, P. M. Am. J. med. Sci. 1940, 200, 23.14. Firestone, G. M. ibid. 1946, 211, 556.15. Atkins, E. in Signs and Symptoms (edited by C. M. MacBryde);

Philadelphia, 1964.16. Ansell, B. M., Bywaters, E. G. L. Ann. rheum. Dis. 1962, 21, 253.

all problems apart from remuneration-which is the

preserve of the Review Body. Meanwhile, implementingthe Ministry’s recommendations for times off-duty andfor study leave will tax the ingenuity of all but the mostlavishly staffed hospitals unless two conditions are met:first, give-and-take between the various units and thechiefs of individual hospitals or groups of hospitals; andsecondly, scrupulous economy in the employment of allhospital doctors, whether senior or junior. The ideal, atpresent rarely fulfilled, is that no work shall be done bya doctor in any grade which can safely be done by one ina lower grade; and that no doctor shall do work that cansuitably be done by one who is not medically qualified.Scandinavian visitors-among others-are horrified byour national profligacy in allowing hospital doctors to

spend long hours on clerical duties: nor should theseduties be shuffled off on to nurses, whose time is no lessvaluable. Britain’s hospitals offer some curious contrasts:mostly they are ancient monuments in which modern andhighly complex techniques are practised with a thought-lessness for the economical use of the professional man’sand woman’s time which is an incongruous remnant fromthe more leisurely days of leeches and blood-letting. Theoutline of a new deal for hospital medical staff which isbeginning to emerge from the round of talks is likely toremain largely a pipedream unless an 0 & M study ofthe hospital doctor’s day is undertaken-and resolutelyacted on.

" IRRITABLE COLON OF CHILDHOOD"

THE time is well within the memory of the middle toolder range of pxdiatricians when the empirical art of the" infant feeder " was much sought after as he threaded hisway through the maze of marasmus, habit vomiting,posseting, ruminating, athrepsia, steatorrhoea, intestinal

hurry, and acid diarrhoea. All this has now passed, andmost of those strange unfounded diagnoses are now ex-plained as hiatus hernia, gastro-oesophageal reflux,electrolyte imbalances, protein dyscrasias, cystic fibrosis,the malabsorption syndrome, and, most recently, the

enzyme deficiencies, notably that of lactase and the otherdisaccharidases.The modern paediatrician, faced with the problems that

confronted his forbears, sets in motion a series of investi-gations, and in a short time often comes up with an estab-lished diagnosis for which there is now a more or less satis-factory treatment. On the other hand, not all these prob-lems are completely understood, and Davidson andWasserman have collected a series of 186 cases inwhich they describe a condition which they call " theirritable colon of childhood (chronic non-specific diar-rhoea syndrome)." They believe this is a clinical entitywhich does not include any of the known causes of diar-rhoea. In brief, these children are between the ages of 1 and3 years; and the diarrhoea comes mainly during the earlywaking hours, with three to four stools a day, small in sizeexcept for the first, and containing mucus and vegetablefibres (if vegetables are in the diet). The condition is quiteunaffected by any treatment, and all the children recoveredspontaneously by the 39th month of age.

Because these children had no discoverable organicdisease, and their physical progress was uninterrupted,Davidson and Wasserman considered two possible causes.The first and most obvious one is psychogenic; but this

1. Davidson, M., Wasserman, R. J. Pœdiat. 1966, 69, 1027.

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they dismiss, favouring a " hereditary predisposition ".Here, we feel, they are taking a step backwards by invokinga diagnosis like the old " gastric neuroses "-which in theend all turned out to be organic-and the illnesses of thesechildren may eventually be similarly explained. One pos-sible cause may be temporary intolerance for certain factorsin the diet. Holzel et al. first described lactase deficiencywhich was congenital and familial, and this condition isspecifically excluded from Davidson and Wasserman’sgroup. On the other hand, evidence seems to be emergingthat there can be a temporary loss of enzyme activity,usually the aftermath of gastroenteritis, which resolvesspontaneously in a matter of months. That would fitin well with the onset after birth and the spontaneousdisappearance of

" the irritable colon". Meanwhile, itis well to recognise this type of case, but its xtiologymight be better regarded as so far unexplained. Psediatric

enzymologists are unravelling this situation, and furtheradvances in our understanding of causes and choice oftreatment will come before long.

SULPHONAMIDES IN MALARIA

INTEREST is growing in the use of sulphonamide drugsas alternative or adjunctive treatment for malaria, particu-larly against resistant Plasmodium falciparum. They aregenerally considered to be competitive inhibitors of

p-aminobenzoic acid (P.A.B.A.), which can be shown toantagonise the action of sulphadiazine against plasmodiumin animals.3 4 The potentiating effect of sulphadiazine onthe activity of pyrimethamine in human P. falciparummalaria was demonstrated by Hurly 5 and confirmed byother workers.6-8 The mechanism of this potentiation isobscure, but it may be that the P.A.B.A. inhibitors such assulphadiazine interfere with the synthesis of folic acidfrom P.A.B.A. or other precursors, while pyrimethamine,like chlorguanide and chlorproguanil, interferes with thesynthesis of folinic acid.4 9

Professor Harinasuta and others now record on p. 1117their experience with a long-acting sulphonamide,sulphormethoxine, in chloroquine-resistant malaria inThailand. A single dose alone cured 11 out of 18 patients,and a smaller dose combined with a single dose of pyri-methamine cured 11 out of 15 patients. A combinationof sulphormethoxine and chloroquine cured 11 out of 13patients. These findings agree with those of other investi-gators,’ 10 -12 and the sum of evidence suggests that themost effective regimen is 1000 mg. of sulphormethoxinecombined with 50 mg. of pyrimethamine in a single dose.Moreover, whereas the response to the sulphonamidealone is slow, the therapeutic effect of the combination israpid.Although Harinasuta et al. found no clinical or labora-

tory evidence of drug toxicity in their patients, sulphor-methoxine has been implicated in cases of Stevens-Johnson2. Holzel, A., Schwarz, V., Sutcliffe, K. W. Lancet, 1959, i, 1126.3. Bishop, A. Biol. Rev. 1959, 34, 445.4. Thompson, P. E. in Annual Review of Pharmacology (edited by H. W.

Elliott); vol. VII, p. 82. Palo Alto, U.S.A., 1967.5. Hurly, M. G. D. Trans. R. Soc. trop. Med. Hyg. 1959, 53, 412.6. McGregor, I. A., Williams, K., Goodwin, L. G. Br. med. J. 1963, ii,

728.7. Laing, A. B. G. ibid. 1964, ii, 1439.8. Laing, A. B. G. ibid. 1965, i, 905.9. Rollo, I. M. Br. J. Pharmac. Chemother. 1955, 10, 208.10. Laing, A. B. G. Bull. Wld Hlth Org. 1966, 34, 308.11. Chin, W., Contacos, P. G., Coatney, G. R., King, H. K. Am. J. trop.

Med. Hyg. 1966, 15, 823.12. Bartelloni, P. J., Sheehy, T. W., Tigertt, W. D. J. Am. med. Ass. 1967,

199, 173.

syndrome,13 and the potential hazards of other long-actingsulphonamide drugs 14 may well apply to this particularcompound. The emergence of drug-resistant malariais a big health problem in most tropical areas, and

although resistance is usually specific for particular drugsor groups of drugs, multiresistant strains also appear. 4On the evidence so far the therapeutic advantages of thisconvenient form of combined treatment in chloroquine-resistant cases outweigh the possible risks of toxic effects.Although, as Harinasuta et al. point out, its injudicioususe may extend drug resistance, it must be welcomed as adistinct advance in malaria control.

THE PUBLIC-HEALTH SERVICE

DOCTORS in the public-health service have been, andremain, underpaid: a departmental officer receives aninitial salary of E1515, rising by eight annual incrementsto E2130. Last June the staff side of committee C of theMedical Whitley Council submitted a claim, based onincreases awarded by the Review Body to other doctorsin the National Health Service, on behalf of doctors inthe public-health service. The employers’ side has

always insisted on offering the staff side the same increases- as comparable grades of other (non-medical) local-

authority employees, without regard to Review Bodyawards; a claim on behalf of one such group (whosenegotiating machinery is entirely separate from theMedical Whitley Council) has been referred to the NationalBoard for Prices and Incomes, whose report is expectedlater this year, and the employers’ side of the MedicalWhitley Council has refused to make an offer until theBoard’s decision is known. Meanwhile the MallabyCommittee on Local Authority Staffing has reported acritical situation in the recruitment of public-healthdoctors.The British Medical Guild (which is the British Medical

Association in its trade-union hat) has now recommendeddoctors not to apply for public-health appointments, andthe British Medical Journal (which is the journal of theAssociation) is to refuse advertisements of public-healthposts, until an acceptable offer of an increase has beenmade. The Lancet, unlike the B.M.J., will continue atpresent to accept advertisements for the public-healthservice. Withholding advertisements can only aggravate a" critical situation " and thus make conditions harder bothfor the public and for an already understaffed service. Theemployers’ side seems to have been-to say the least-dilatory, but this hardly justifies a declaration of war. Noagreement has been broken; the employers’ side is notbound by the Review Body’s findings. The truth is thatpublic-health doctors, now grossly underpaid, were

already somewhat underpaid when the staff side first gavenotice of its claim in November, 1965; and the presentunsatisfactory situation is the unhappy outcome of pastfailure to secure a reasonable level of remuneration in theservice. The Association, we believe, is right to seek torelate pay of doctors in the public-health service to thatof doctors elsewhere in the N.H.S.; and it can reasonablyexpect more support in this endeavour than it hashitherto received from a hospital-minded Ministry ofHealth. But the negativisitic attitude reflected in theAssociation’s latest action is unlikely to promote this

change.13. Meyler, L. Side Effects of Drugs; vol. v, p. 272. Amsterdam, 1966.14. Lancet, Jan. 21, 1967, p. 150.