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and the earliest possible restoration of function wasadvocated.

In the foot to reconstruct the skeleton is thesurest means of restoring function. Eastwood,1 it istrue, has recently reported a series of fractures of theos calcis in which good function was restored withoutattempting to reduce the deformity. But most surgeonsinsist that strong and painless feet are obtained onlywhen the alignment of joint surfaces is as nearly aspossible anatomical. Mr. Gordon Irwin said thathis investigation of the results obtained by modernmethod has convinced him that all the efforts at

efficiency had justified themselves. The insurance

companies’ statistics showed that the period of dis-ability in fractures of the metatarsals had been cutdown to a half or two-thirds of that of ten years ago.All his patients with these fractures now returned tofull work, and this most often meant heavy industriallabour. The two principles of modern treatment wereaccurate anatomical reduction of deformities andfixation in a plaster splint that allowed walkingwithout weight-bearing on the fractured bones. Hebelieved that the stress of using the limb is one of themost potent factors in ensuring bony union. An

important consideration in restoring a foot to normalfunction is the length and shape of the first meta-tarsal. Impaction of this bone in malposition mustbe very carefully corrected, and if there is angulationof its shaft, it is far better that it should be bentdorsalwards than plantarwards. Continuous tractionto correct shortening may be necessary in fractures ofmetatarsals. Mr. Irwin drew attention to the greatdanger of forcible manipulation to mould fracturedfeet in a late stage when there was much swelling andoedema, for this might cause gangrene of the foot

necessitating amputation. Gradual traction byBohler’s method was much safer than manual

manipulation at this stage. During the late war," march foot " in young recruits attracted consider-able attention. It is known that this particularvariety of painful foot is due to a fracture of one ofthe middle three metatarsal bones across its neck.Mr. Irwin finds this same fracture in nurses duringthe early months of their training. He attributes the

injury to a sprain of the interossei followed by oedemaand by decalcification of the metatarsals. Weight-bearing then cracks the weakest bone or that bearingthe most strain. It is most important that immobilisa-tion of the foot should be prolonged until it is firmlyconsolidated if recurrence is to be avoided.

THE NORMAL ELECTRO-ENCEPHALOGRAM

THE rapidity with which physiological discoveriesare absorbed into clinical science sometimes preventsdue attention being paid to the scientific significanceof the discoveries themselves. The successful applica-tion of electro-encephalography to neurologicaldiagnosis must not conceal either the empirical natureof the technique or the importance of experimentson normal subjects. A paper by Jasper and Andrews 2shows how little is known and how much may yetbe discovered about the electrophysiology of thenormal human cortex. Using apparatus and methodsalmost identical with those developed in this countryfor the diagnosis of cerebral tumours and epilepsy,these American workers claim that there are at leasttwo, and possibly three or more, distinguishable

. electrical rhythms in the normal brain, and thatthese rhythms are localised in origin. The " alpha

1 Eastwood, W. J., Brit. J. Surg. 1938, 25, 636.2 Jasper, H. H., and Andrews, H. L., Arch. Neurol. Psychiat.,

Chicago, January, 1938, p. 95.

potentials, which were for some time called the" Berger rhythm," have a frequency of about 10 persec., are inhibited by visual activity, and are mostprominent in the occipital region. The 25 per sec." beta " rhythm is more characteristic of the pre-central cortex and is sensitive to inhibition byunexpected touching of the body. The " gamma

"

rhythm is even faster, and little is known about it

except that it is rare. These potential rhythms seemto resemble in some ways the characteristic localaction potentials described by Kornmiiller 3 in animals,but the variability between individuals and in thesame individual from time to time is very much greaterin the human subject, and the hoped-for correlationbetween electrical rhythm, histological structure, andphysiological function is still far from established.The most striking property common to all these

brain rhythms, at least the one most puzzling to thephysician, is that they all-visual alpha, sensori-motor beta, problematical gamma, and patho-logical delta-seem to indicate varying degrees ofrest on the part of the cortex. Perhaps, in order todistinguish them from the fading memories of text-book physiology, we should call them " inaction

potentials."BARBITURATE POISONING

THE barbitone group of hypnotics form a convenientif uncertain vehicle for the suicide, and in Francethere have been intermittent epidemics of their usefor this purpose. Carriere and Huriez 4 of Lille saw32 cases of barbiturate poisoning in the four years1934-37 with 7 deaths. Of the persons concerned27 took phenobarbitone, 2 Veronal, 2 Allonal, and1 Dial ; 25 were women and 7 men. They could bedivided into three classes, according to the dose ofdrug taken : a

" subcomatose"’ class who took from1 to 2 grammes and recovered spontaneously aftersleeping 10-20 hours ; a " curable comatose " classwho recovered with treatment after being comatosefor 3-20 hours ; and a " malignant

" class who tookfrom 6 to 11 grammes and died after a coma lasting21-72 hours. The prognosis, then, depended largelyupon the dose taken, though people have been knownto recover after taking as much as 15 g. of veronal.

Age and previous medical history did not seem

important in this series, but the outcome was influencedby delay before treatment was started. The curedcases all received treatment within ten hours, whereasall but one of the fatal cases were treated later.Serious signs during the coma were : a temperatureover 102° F. ; a considerable increase in leucocytes,especially polymorphs ; extensive chest complica-tions ; a severe fall in blood pressure ; and signs ofrenal failure. One woman of 22, who died after

taking 6 g. of phenobarbitone, had a temperatureof 105° F., a white cell count of 40,000, including90 per cent. polymorphs, and an extensive broncho-pneumonia. Carriere and Huriez advise preliminarygastric lavage or apomorphine, then adrenaline or

Coramine (3 c.cm. hourly intravenously) if there is

circulatory depression, bleeding if there is cyanosis,and oxygen if there are pulmonary complications.In severe cases they give a 30 per cent. solution ofalcohol intravenously every two hours. Thoughcoramine and alcohol neutralise the effects of thebarbiturates in animals, they have not been strikinglysuccessful in man, and Carriere and Huriez pin theirfaith to strychnine. Where this can be given within

3 Kornmüller, D. E., Die bioelektrischen Erscheinungen derHirnrindenfelder, Leipzig, 1937.

4 Carrière, G., and Huriez, C., Echo méd. Nord. December,1937, p. 687.

389

two or three hours. they say a dose of 20-50 mg.of strychnine sulphate every 20 or 30 minutes willbring a patient out of coma in a few hours, thoughthey admit that there is some danger of strychninepoisoning. One of their patients, however, died

although she was treated within two hours and givena total of 785 nig. of strychnine.

Strychnine certainly cannot be regarded as aspecific, and wider trial should perhaps be made ofpicrotoxin. The use of this remedy in chloral hydratepoisoning was suggested by the late Sir JamesCrichton Browne in 1875, and Maloney, Fitch, andTatum (1931) found it more effective than strychninein barbiturate poisoning of animals. Kline, Bigg, andWhitney5 gave it successfully to a student of 20 whotook thirty Amytal tablets, a total of 3 g., and becamedeeply comatose. His stomach was washed out and23 doses of 0-003 g. of picrotoxin were given sub-cutaneously within the next sixteen hours, with

glucose intravenously. After this period he beganto move about and recovered uneventfully. He hadshown, however, none of the signs that the Frenchwriters consider to be of serious import.

STERNAL PUNCTURE

IN the last few years examination of bone-marrowremoved by sternal puncture has become a routinein several hasmatological clinics. A valuable reviewof 246 cases studied by this method has been pub-lished by Vogel, Erf, and Rosenthal. 6 Their dif.ferential counts on a series of normal marrow samplesclosely agree with those of other observers. Theyconclude that sternal puncture is useful in the diag-nosis of Gaucher’s disease, myelomatosis, leish-

maniasis, malaria, and carcinoma with generalisedbone metastases, and particularly in aleuksemic typesof leukaemia. They found it also of confirmatoryvalue in leukaemia, leucopenic infectious mono-

cytosis, agranulocytosis, pernicious anaemia, sprue,hsemolytic jaundice, polycythsemia, and aplasticanaemia. In haemolytic jaundice the marrow is normo-blastic. which allows a rapid differential diagnosis tobe made in cases of chronic jaundice. Polycythsemiashowed two interesting marrow characteristics-the erythropoietic elements were decreased in number,and the predominating cells were mature polymor-phonuclear leucocytes. In conditions other thanthose mentioned a study of the marrow was notfound helpful. Unfortunately from the paper theclinical differentiation between what the authorscall leucopenic infectious monocytosis and agranulo-cytosis is not altogether clear, though from readingthe case reports it appears that the former title is

given arbitrarily to cases with agranulocytosis in theperipheral blood that recover and the latter to thosethat do not. They state that the number of nucleatedmarrow cells was normal in the benign type-inwhich also there is an increased number of myelo-cytes-but greatly diminished in the fatal form.Where the monocytes originate is still obscure.

It is of interest, therefore, that in this series of 246patients monocytes were found in the marrow onlytwice, though 5 cases with an increase in the peri-pheral blood were studied. No apparent variationin the quality or quantity of cytoplasm of the mega-karyocytes was found in 9 patients with thrombo-cytopenic purpura, and splenectomy had no effecton them though the peripheral platelets rose

to normal. In infectious mononucleosis the marrow

5 Kline, E. M., Bigg, E., and Whitney, H. A. K., J. Amer.med. Ass. 1937, 109, 328.

6 Vogel, P., Erf, L. A., and Rosenthal, N., Amer. J. clin.Path. 1937, 7, 436.

always showed an increase in lymphocytes. Nocorrelation was found between the number of eosino-

phils in the peripheral blood and those in the marrowin a miscellaneous group of patients with eosinophilia.The illustrations to this study are not helpful, but asmall monograph on the same subject by Schulten 7has some excellent colour prints of the marrow

pictures in different diseases. -All those who have experience of this method of

studying patients with blood dyscrasias agree thatin a proportion of cases it assists in diagnosis. It is

clearly a useful means of analysing the marrow

reactions in obscure conditions such as agranulo-cytosis and obscure anaemias as has been emphasisedrecently in our columns by Zanaty.8

MALE HORMONES IN GYNÆCOLOGICAL

PRACTICE

THE paper by Dr. Loeser on p. 373 raises a questionrelated to one discussed in a leading article last

week-namely, the suggested treatment of chronic

cystic mastitis with oestrogenic hormone. The basisof such therapy is the observation in animals that anexcess of oestrin in the blood depresses the gonad-stimulating powers of the pituitary, and thus leads toa decrease in the amount of oestrin secreted by theovaries. Dr. Loeser has treated ten cases of menor-

rhagia. and two of chronic cystic mastitis, withtestosterone propionate, and he thinks that thesuccess achieved is similarly due to suppression ofthe gonadotropic activity of the pituitary and to aconsequent reduction of ovarian secretion. Thattestosterone can in fact suppress ovarian activityand uterine bleeding has been shown by Zuckerman,9 9working on monkeys, and one part of Dr. Loeser’s

speculation thus has an empirical foundation.Observations published by Salmon 10 provide somefactual basis for the second part of his speculation.Ovariectomised women, or menopausal women withfailing ovarian function, excrete more gonadotropichormone and less cestrogenic hormone than donormal women. Salmon investigated a patient,aged 46, whose ovaries and uterus had been removedat operation and who suffered from typical meno-pausal symptoms. He found that the injection oftestosterone propionate gave considerable relief fromthe symptoms and also reduced the amount of

gonadotropic hormone recoverable from the urine.

Simultaneously the vaginal smear was transformedfrom the " ancestrous " to the " oestrous " type.These observations suggest-though they certainlydo not prove-that testosterone propionate does infact cause changes in the pituitary.

In considering the complicated reactions withwhich Dr. Loeser is dealing one must bear in mindthat he provides no direct evidence that ovarian

activity was suppressed in the patients he treated.Testosterone propionate does not necessarily havethe same action on the ovaries of different species,and it is perhaps unsafe to transfer to womenobservations that have been made on monkeys.For example, Me Keown and Zuckerman’-1 have shownthat in the rat the inhibition of uterine changeswhich the hormone causes is associated with luteinisa-tion ; and here, too, it is unknown whether or not

7 Die Sternalpunktion als diagnostiche Methode. By Prof.Dr. Hans Schulten. Leipzig: Georg Thieme. 1937. Pp. 82.R.M. 18.

8 Zanaty, A. F , Lancet, 1937, 2, 958, 1365.9 Zuckerman, S., Lancet, 1937, 2, 676.

10 Salmon, U. J., Proc. Soc. exp. Biol., N.Y. 1937, 37, 488.11 McKeown, T., and Zuckerman, S., Proc. roy. Soc. B, 1937,

124, 362.