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safe posture for unconscious subjects. The donor kneltbehind the subject’s head, using one knee to support andextend the neck, and performed expired-air resuscitation.Carbon-dioxide tensions, airway pressures in the donor,and arterial oxygen saturation in the subject were studied.Resuscitation was no less effective in this than in theorthodox position. It may well be more tiring, though inthis study it was given for sixteen minutes on the floorwithout great exertion and could have been continued for

longer.Circumstances in which this variant of the method is

to be preferred may arise quite often, and it should bemore widely known.

NITROFURANTOIN

NITROFURANTOIN is a bacteriostatic agent which acts on

many coccal and bacillary pathogens!; but it has a singu-larly narrow therapeutic province,2 for outside the urinarytract it is practically useless. When excreted in the urinarytract, it is valuable for controlling, if not eradicating,various infections, especially in cases of congenital orobstructive lesions where long-term therapy is requiredto prevent or suppress chronic infection due to coliform

organisms or proteus. 3-5Given by mouth, nitrofurantoin does not reach a

bacteriostatic level in the blood or tissues, but it doesreach such a level in the urine. To assess the possibleadvantage of producing a bacteriostatic concentration inthe blood and tissues, Halliday and Jawetz 6 administeredthe soluble sodium salt as a slow intravenous infusion in10 patients with urinary infections. This produced, asmight be expected, high concentrations of the drug in theurine, but little or none in the serum. The case-records(given for 8 of their 10 patients) suggest that the infectionswere on the whole rapidly controlled, but some curiousincidental effects were observed. One patient, describedas having renal tubular acidosis, had no measurableamount of drug in the serum and only 10 I-Lg. per ml. inthe urine, despite a total dosage of 3-16 g. intravenouslyin eight days. This patient showed no toxic signs, but herurinary coliform infection was unaffected by the therapy.Another patient, with pyuria due to Proteus vulgaris,received 5-4 g. in ten days, with a maximum urinary levelof 240 jjt.g. per ml. The strain of proteus was relativelyresistant, requiring 96 (ig. per ml. for partial inhibition,and bacilluria was scarcely checked. In this patient thedevelopment of an abnormal cephalin flocculation test

suggested hepatic disorder during therapy. Another

patient, with well-controlled diabetes, had sudden

glycosuria and ketonuria.Since nitrofurantoin is not entirely non-toxic even when

given by mouth 5 the results described by Halliday andJawetz are unlikely to encourage its intravenous adminis-tration. Indeed on an earlier occasion when a solutionin polyethylene glycol was given intravenously, the con-sequences were quite disastrous. The sodium salt is

clearly much less toxic; but, even in high doses, it failsto circulate in active form in the blood and is therefore

1. Mintzer, S., Kadison, E. R., Shales, W. H., Felsenfeld, O. Antibiot.Chemother. 1953, 3, 151.

2. Jawetz, E., Hopper, J., Smith, D. R. Arch. intern. Med. 1957, 100, 549.3. Heffernan, S. J., Kippax, P. W., Pamplin, W. A. V. J. clin. Path. 1955,

8, 123.4. Waisbren, B. A., Crowley, W. Arch. intern. Med. 1955, 95, 653.5. McGeown, M. G. Brit. med. J. 1956, ii, 274.6. Halliday, A., Jawetz, E. New Engl. J. Med. 1962, 266, 427.7. West, M., Zimmerman, H. J. J. Amer. med. Ass. 1956, 162, 637.8. McCabe, W. R., Jackson, G. G., Grieble, H. G. Arch. intern. Med.

1959, 104, 710.

not indicated for the treatment of systemic infections. Inview of its rapid excretion in high concentration in theurine, Halliday and Jawetz suggest that intravenousinfusions of sodium nitrofurantoin should be adminis-tered to acutely ill, nauseated, or vomiting patients withurinary infections. This may be good counsel if noalternative drug is available.

INADVERTENT HYPOTHERMIA

IT has been known for many years that the temperaturesof children undergoing general anaesthesia are unstable.For a time interest centred mainly on the risk of hyper-pyrexia as a result of overheating from too much mackin-tosh sheeting and perhaps also of inhibition by atropine ofthe normal sweating mechanism. At the other extreme,accidental hypothermia has appeared in very young chil-dren, in the absence of anaesthesia and operation, as " coldinjury "-a condition which has a not inconsiderablemortality 1 2 and may give rise to serious sequelae Ittherefore now seems important to prevent a fall in

temperature 4-a complication which is especially liableto develop during operative treatment of hydrocephalus.1 5

This concern with preventing a fall in body-temperatureis not entirely easy to understand. When hypothermia wasfirst introduced into surgical practice, it seemed to be

particularly applicable to bad-risk cases in which the

patient might not survive a surgical procedure carried outat normal body-temperature .6 Why then is not hypo-thermia, however produced, beneficial rather than harmful?In the adult, ventricular fibrillation may develop at

temperatures below 30°C and spontaneous respiratoryarrest at a temperature of 26°C. But in the reported seriesof cases of inadvertent hypothermia in children underanaesthesia, there is no suggestion that the temperatureever reached such dangerous levels, and the only problemswere a somewhat delayed recovery of consciousness anda delay in restarting feeding.5 5 Sclerema 8 apparentlycaused difficulty in a child who was’cooled for operation,but this complication seemed to be amenable to steroidtherapy.4 4

There is thus no evidence to resolve the apparentcontradiction between, on the one hand, the not very wellsubstantiated desirability of lowering the temperatures ofadults to enable them to survive major operations and,on the other hand, the undesirable effects of inadvertenthypothermia in children. It is fairly clear that halothane,with its profound vasodilator action, greatly increases heatloss. There is need, therefore, for maintaining by somemeans the temperatures of young children to whom it is

given; and this agent has so many other advantages thatthe additional trouble is worth while. Apparently wrap-ping a child in cotton-wool will go far towards keeping itstemperature nearer normal. A mattress with water circu-

lating through it may be even more effective.5

Sir CHARLES DoDDS, F.R.S., has been elected presidentof the Royal College of Physicians of London for the ensuingyear.

1. Mann, T. P., Elliott, R. I. K. Lancet, 1957, i, 229.2. Bower, B. D., Jones, L. F., Weeks, M. M. Brit. med. J. 1960, i, 303.3. Gordon, R. R. Lancet, March 3, 1962, p. 460.4. Gough, M. H. Arch. Dis. Childh. 1960, 35, 66.5. Calvert, D. G. Anœsthesia, 1962, 17, 29.6. Laborit, H., Hugenard, P. Pr. méd. 1951, 59, 1329.7. Gray, T. C. Proc. R. Soc. Med. 1935, 48, 1083.8. Hughes, W. E., Hammond, M. L. J. Pediat. 1948, 32, 676.9. Blake, H. H., Goyette, E. M., Lyter, C. C., Swan, H. ibid. 1955, 46, 78.