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variation in the absorption and acetylation of sulphon-amides is well known, and it is because of this variationthat estimations of the sulphonamide level in the bloodare so important. Without them it is impossible to tellwhether absence of therapeutic response is due to

inadequate absorption or distribution of the drug, or toinsensitivity of the infecting organism.A single dose of 9 g., provided that vomiting does not

occur and that absorption is normal, would be expectedto raise the sulphonamide concentration in the blood tobetween 10 and 20 mg. per 100 c.cm. within a few hours.This is unlikely to be maintained for long and the levelwill fall progressively during the next 24 hours or more,being probably too low to be effective for the greaterpart of that period. Consequently the organism will besubjected to an effective dose for a short time, but to aninadequate dose for a somewhat longer period, which issurely the danger which Golden and Meyer claim toavoid. Their suggestion that the massive-dose methodenables the physician to discover the best chemothera-peutic agent by trial and error within 7 days appearsunsound, for unless the blood concentration is known atherapeutic assessment of the sulphonamide being usedcannot be made.The clinical evidence which Golden and Meyer produce

in support of their hypothesis is slight-their paper isintended to be only a preliminary report. In no caseare sulphonamide blood levels recorded. At least 6 ofthe 8 cases described are of an indeterminate characterwith an unpredictable natural course, and several seemto indicate the inadequacy of the single-dose methodrather than its efficacy. It may be that an infectionwith a highly sulphonamide-sensitive organism could becontrolled under certain circumstances by a single dose,but as a routine method the procedure advocated byGolden and Meyer cannot be recommended on theoretical,experimental, or clinical grounds.

MALARIA AMONG MERCHANT SEAMEN

Ix the past, merchant seamen have suffered heavilyfrom malaria contracted during calls at ports in the

tropics. The disease usually declared itself after the

ship had put to sea beyond the reach of medical help ;consequently it often escaped recognition until it hadreached a stage where treatment was seriously handi-capped, and many valuable lives were lost. Apart fromthis, if many of the crew were laid up at one time, theship and the lives of all on board might be exposed toserious risks from understaffing and consequent over-

strain for those who remained on duty. The Ministryof War Transport is therefore to be congratulated onproducing two excellent memoranda (revising earlier

publications) on the prevention and treatment of malariaamong merchant seamen, one intended primarily formasters of ships which do not carry a doctor, and theother for ships’ surgeons.2 Each of these is clear,up to date, accurate, and practical. That for masters ofvessels is the more interesting, and ships’ surgeons shouldcertainly not neglect it.

If the advice given in these memoranda is faithfullyacted on-it often seems strangely difficult to ensurethe necessary cooperation of men whose own health is inquestion-there should be very little malaria on ships,and no deaths. Only one point seems to need recon-sidering : the treatment of severe malaria complicatedby vomiting. The memorandum to shipmasters rightlysays that " the correct treatment is to administer quinineintravenously or mepacrine intramuscularly," but wefind it hard to accept as inevitable the restriction whichfollows-" but this cannot be done unless there is a

1. Malaria Among Merchant Seamen. Ministry of War Trans-port Notice no. M.178. Revised November, 1945. Pp. 9.

2. Ministry of War Transport Notice no. M.195. RevisedNovember, 1945. Pp. 25.

qualified doctor on board." The alternative measuresadvised are orthodox enough : bicarbonate of soda inwarm water, hot fomentations or a mustard leaf to theabdomen, sucking of ice, and sedatives.. If thesemeasures fail and the vomiting persists, the advice isthat, after 12 hours : " ... mepacrine (if it cannot beadministered intramuscularly or intravenously) must beadministered by the lower bowel (per rectum)." Unfor-

tunatly the measures advised will seldom controlvomiting in malignant tertian (P. falciparum) malaria,and rectal administration of mepacrine may often fail.In any case, valuable time will have been lost. It seemsworth considering whether it would not be possible totrain an intelligent member of each crew to give intra-muscular injections of mepacrine. The dangers of sepsisor injury from bad technique are not to be underrated,but experience shows that laymen can easily be taughtto give an intramuscular injection, and that when theyare well trained their methods are not inferior to thoseof most qualified doctors. Malaria with vomiting is a

potentially grave condition, and it seems likely thatmany more lives would be saved than abscesses or

injuries inflicted by a prompt intramuscular injection ofmepacrine-even if this had sometimes to be given bysomeone who was not a qualified doctor.

AMERICAN LIMB-FITTING

IN dealing with amputations, the American armyhave developed methods which differ somewhat fromours. A report by a subcommittee of civilian con-

sultants, just published by the American War Depart-ment, illustrates some of these differences and alsoshows how actively the study of limb-fitting is now

progressing in America. The consultants forming thesubcommittee were Dr. Harold Conn, orthopaedicspecialist at Akron, Ohio; Dr. Paul B. Magnuson,associate professor of surgery at Northwestern Universitymedical school; and Dr. Philip D. Wilson, clinicalprofessor of orthopaedic surgery at Columbia UniversityCollege of Physicians and Surgeons; they have allserved on the orthopaedic subcommittee of the NationalResearch Council since 1941. They visited army hospi-tals in Michigan, Utah, Texas, Georgia, Virginia, andWashington D.C. To us, who have so often heardit condemned, it is surprising to read that GeneralNorman D. Kirk, soon after his appointment as Surgeon-General, directed that all primary major amputationsin the forward area should be done by the guillotinemethod : and that the subcommittee believe that sternenforcement of this policy has saved countless lives,conserved stump length, and yielded the best amputa-tion stumps that have ever been obtained. They notethat after the operation adequate traction must be

applied to the skin of the stump if sufficient soft-tissuecovering is to be obtained without unnecessary loss ofbone length. They saw stumps in various stages of

healing, many of them showing unhealed granulatingwounds which had to be excised before the skin couldbe closed, but the fact that most guillotined stumpsrequire " surgical revision " after reaching the base doesnot seem to them a serious objection to the method, andthe great tenderness of granulating stumps is notmentioned in the report, though it is noted that painfulstumps and phantom limbs were rare. They concludethat the surgical treatment of the amputation cases

given in the late war is better than any they havepreviously seen, and far better than in 1914-18,thanks to better treatment of the patient from the timeof his injury, better surgery, and the reduced incidenceof infections due to modern methods of chemotherapy.

Early in 1943 the American Medical Corps adoptedthe Trautman artificial limb, which is made of woodfibre. Some weaknesses in the original ankle mechanismsare being overcome, and more sizable feet, of the slipper

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type, are being supplied, the original type having beentoo small and too slender in the instep. The stump

sockets were at first made of leather, moulded over aplaster model of the.stump, and then fitted into the shin-piece. Sockets made of a plastic called Celastic’promised to be lighter and more sanitary, but failed tokeep their shape and had to be given up. ’Bakelite’seems likely to be more successful. Limbs made entirelyof plastic or of ’Duralumin ’ alloy were not thought tohave any clearly demonstrable advantage over wood-fibre limbs.The subcommittee thought highly of the programmes

in action for reabling the men who had lost limbs.Those who have lost upper limbs are trained in the useof their appliances by occupational therapists. Theyundertake bench work, gardening, car-driving, writing,eating, and personal care. They are required to pass astiff test of accomplishment before being discharged fromthe army. Those who have lost legs are trained by thedepartments of physical therapy and reconditioning,and are expected to march to music, and to walk overrough obstacles and loose materials and up and downstairs. During this period of training it is possible todecide whether the limb fits comfortably or is likely tocause abrasions.The limb shops are said to compare favourably with

the best civilian shops the subcommittee have seen,and those working in them showed a keen desire toimprove appliances and carry out research. New

surgical developments include attempts to improve theChopart amputation stumps by fusing the ankle andsubastragalar joints, and to improve the efficiency ofshort below-elbow and below-knee stumps by dividingthe flexor muscles. Prosthetic improvements include acompound elbow-joint to increase the movement ofshort stumps, and a double elbow-joint to increase theflexibility of below-elbow stumps.

STUDENTS’ FILM UNIT

A FILM unit has been formed by a group of studentsat Guy’s Hospital who are interested in the possibilitiesof the cinema in medical teaching. The unit is beingencouraged by the medical school council, who are

lending equipment, and advised by members of thestaff who have some experience of medical cinephoto-graphy. The aim is to make simple instructional films

, for use in conjunction with lectures to students, ratherthan specialised films for postgraduate medical audiencesor propaganda films for the general public. The unit isnow producing a film called Actions of Muscles,which will illustrate the functions of muscles in relationto one another and to the skeleton as a lever system.The films made will be silent, because the cost and tech-nical complexities of sound production would be toogreat for an amateur unit. If a considerable part of thefilm is not to consist of titles and subtitles it will be

necessary for the lecturer to supply a commentaryduring the showing of the film. This can be consideredan advantage, for it prevents the subject of the filmfrom being treated too rigidly and allows the emphasisto be laid on different aspects according to the lecturer’srequirements. Moreover, a silent film can be used bystudents, with a special viewing apparatus, for individualstudy, and, as Longland and MacKeith have suggested,a few titles, together with a handbook, will enable thefilm to be easily understood. Production is necessarilyslow, since this is entirely a student unit and work onthe film can be done only when the members can gettogether. Fortunately this limitation is not so seriousonce the scenario has been agreed on, for then the variousgroups, each consisting of a small number of students,such as animators, titlers, and those concerned with thefilming of the living models, can work on their part of

1. Longland, C. J., MacKeith, R. Lancet, 1944, ii, 585.

the production in their own time. The unit hopes toproduce some useful films ; but its members also hopeto gain a knowledge of medical photography which willbe of use and interest to them after they have qualified.

TOXICITY OF OXYGEN

SooN after his discovery of oxygen Priestley suggestedthat, while oxygen might be " peculiarly salutary to thelungs in certain morbid cases," it might also have harmfuleffects. Today, when concentrations of oxygen up to100% can be administered with a portable mask, itmust be realised that oxygen is not exempt from theold adage about having too much of a good thing. A highpartial pressure of oxygen in the alveolar air may resulteither from breathing increased concentrations at

atmospheric pressure, as in therapeutics, or from breath-ing normal air at an increased pressure, -as in diving.The stream of publications on this subject, both inAmerica and in this country, has been based largely onwork done for the naval authorities. As a result of these

investigations, outstanding among which are the contri-butions of Sir Leonard Hill, diving to 400 feet is now assafe as crossing Piccadilly Circus, but, as has been wellbrought out in two authoritative surveys,12 there isstill doubt about the precise means whereby oxygenproduces its toxic effects. One of the difficulties is thatin dealing with air breathed under pressure there arevarious factors that are potentially toxic, apart fromthe increased pressure of oxygen. These variablesinclude the effect of increased pressure itself, the increasednitrogen pressure, and the increased pressure of carbondioxide.

’

Allowing for these variables, it seems that the toxiceffect of oxygen is exercised mainly on the nervoussystem, the respiratory system, and the enzymaticsystem of the body. This last effect is the most difficultto investigate, and it is only in the last few years thatrefinements in technique have permitted reliable experi-ments to be carried out. Stadie and his colleagues 1believe that " the toxic action of high pressures of

oxygen will be explained in the light of inhibitory actionon enzymes, with resultant severe disturbance of essentialmetabolic cellular reaction." Ever since the publicationof Bert’s classical monograph’ the convulsive action ofhigh concentrations of oxygen has been repeatedly con-firmed experimentally in animals, and there have beenreports of similar reactions in man. One of the first ofthese in this ’:country was that of Thomson 4 whodescribed convulsions in a naval officer who had breathedfour atmospheres of oxygen for 13 minutes. A similarreaction was reported by Case and Haldane. 5 Themental effects of oxygen in man were investigated byPhillips who found that the personality type of theindividual played an important part, and, as Bean

remarks, this psychological factor must always beremembered in assessing the significance of neuromusculardisturbances in man. The mental disturbances describedby Phillips occurred at a pressure corresponding to1-4-1-6 6 atmospheres of oxygen. But the dominant

changes with high concentrations of oxygen (0-8-2.0atmospheres) occur in the lungs, where the findings mayinclude congestion, oedema, or pneumonia. In the ratmassive pleural effusions occur after exposure to1 atmosphere of oxygen.7 7That the inhalation of 100% oxygen is not free from

risks is suggested by a recent report from Comroeand his colleagues 8 in the United States. In 90 healthy1. Stadie, W. C., Riggs, B. C., Haugaard, N. Amer. J. med. Sci.

1944, 207, 84.2. Bean, J. W. Physiol. Rev. 1945, 25, 1.3. Bert, P. La Pression Barometrique, Paris, 1878.4. Thomson, W. A. R. Brit. med. J. 1935, ii, 208.5. Case, E. M., Haldane, J. B. S.. J. Hyg., Camb. 1941, 41, 225.6. Phillips, A. E. Proc. R. Soc. Med. 1931-32, 25, 693.7. Boycott, A. E., Oakley, C. L. J. Path. Bact. 1932, 35, 468.8. Comroe, J. H., Dripps, R. D., Dumke, P. R., Deming, M.

J. Amer. med. Ass. 1945, 128, 710.