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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.