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doubtful whether operation within seven days isstrictly to be regarded as emergency operation:it is certain that many surgeons would not so regardit. They might well argue that some at least of the6 deaths in the first group might have been savedby immediate operation. Wilson and McKeeverattribute the lower mortality of the delayed operationto the power of the body to localise the disease, andto the effect of general treatment in improving theresistance of the child. The difficulty of predictingthe degree of localisation in any manifestation of

staphylococcal infection is well recognised, and thefulminating course of the illness in some cases of

osteomyelitis would be likely to cause death in thefirst week. In other words, almost all the fulminatingcases would tend to be operated on early and, havinga high mortality, would swell the number of deathsamongst cases subjected to early operation. Thefact, however, that of 12 deaths amongst the 98 casesof diffuse osteomyelitis 5 occurred within twenty-fourhours of operation, does suggest that the operationitself may have been a definite factor in precipitatingthe fatal outcome. To regard the operation inacute osteomyelitis as urgent in the same degreeas laparotomy in, for example, a case of perforatedpeptic ulcer is probably wrong. Splinting of thelimb, combined with treatment to combat shockand dehydration, will tend so far to improve generalresistance as to make operation a great deal safer.Whether the surgeon should then deliberately awaitlocalisation of the septic process for a further sevento twenty-eight days is another question. To answerit, comparison is required of the results of suchdelay with the results of operation within, say,forty-eight hours of onset of the disease.

THE HOME CONTACT IN MEASLES

THE exclusion from school of the children of ahousehold infected with measles was recommendedin 1927 by a joint memorandum of the Ministry ofHealth and the Board of Education, and has beenwidely adopted. On p. 457 Dr. Duncan Forbescriticises the memorandum and gives good reasonsfor urging its revision. The rate of spread of anepidemic in a school, he says, is only slightly decreasedby excluding home contacts, and within a few weeksoften all the non-immune have been infected to someextent, in spite of this measure. Far more importantthan the doubtful benefits of exclusion is the dangerof the epidemic being given wider scope by thepossibly infectious contact being at large amongthe children of the neighbourhood, and particularlyamong those younger children who are at the worst

age to receive the disease. The infection is carried

by directly inhaled spray, and only rarely by fomites,and in any case, Dr. Forbes believes, it is safer forthe contacts to be under the constant skilled super-vision that is given in the school. Since 1923 homecontacts in Brighton have not been excluded, unless,as is often the case, different members of the familyattend different and uninfected schools. If theweather is cold and wintry or the environment ofthe school unhealthy, delicate children and thoseunder 5 may be excluded. This applies also to mem-bers of families with children under 3, though theadult serum offered to these children should makethis unnecessary if the offer were appreciated by theparents. This system, Dr. Forbes reports, has metwith considerable opposition from both practitionersand laymen, chiefly because it goes against the officialmemorandum, in spite of the evidence that, at theleast, no harm has resulted. By its means, how-

ever, he hopes to reduce the mortality and complica-tions, for it allows of early diagnosis and treatmentin the first days of the attack, besides checking thedanger to pre-school children of uninfected families.

FRACTURE TREATMENT IN BRIEF

OUR advertisement columns, this week and last,contain a welcome announcement. At the LiverpoolRoyal Infirmary from Oct. 12th to 17th there is tobe an intensive course on traumatic surgery whichwill include lectures, demonstrations, and practicalclasses on the treatment of fractures and jointinjuries. The 20 members of the course will be advisedon radiographic diagnosis, on the application of

plasters and splints, and on the organisation of afracture clinic. The arrangements have been madewith the idea of helping surgeons who may be calledupon to take charge of one of the fracture clinicsnow being set up or reorganised at hospitals, and itis supposed that many of these will appreciate thechance of seeing a well-established clinic in action.The prestige of the Liverpool school ensures readyacceptance of its attractive offer.

HYPERTENSION IN PRACTICE

OF two recent papers on high blood pressure,the first, by A. Carlton Ernstene, reviews the varioustypes of arterial hypertension and their recognition.The author rightly regards essential hypertension(hyperpiesia) as the commonest type, but estimatesthat in 10 per cent. of such cases the patient diesof uraemia. Since, in uncomplicated hyperpiesia, theblow falls primarily on the cardiovascular rather thanthe renal system, this figure is surely too high;for, theoretically at least, no one with hyperpiesiashould last long enough to die of renal failure ; inthe absence of intercurrent disease, the heart or

arteries must give out first. There is, moreover, muchto be said against the classification of essential

hypertension, according to the ophthalmoscopicpicture, into benign, intermediate, and malignantgroups. Most pathologists, and indeed many clinicians,hold that these so-called malignant cases are merelychronic cases of glomerulo-nephritis and consequentlynot cases of essential but of renal hypertension.To say therefore that a benign case may " becomemalignant " is merely to shelve the problem ofdifferential diagnosis so vital from the point ofview of prognosis. Ernstene very properly looksupon the age of the patient as of more importancein differential diagnosis than the actual height of theblood pressure, but when he says that extremely highpressures are commoner in essential hypertensionthan in glomerulo-nephritis, and that congestivemyocardial failure occurs in only " a small number "of renal hypertensives, many will disagree with him.Turning to other conditions in which hypertensionmay be encountered, he refers to urinary obstructionand polycystic disease of the kidneys, lead-poisoning,coarctation of the aorta, and Cushing’s syndrome.The hypertension of pregnancy, he reminds us, maybe due not only to pre-eclamptic toxaemia, but alsoto hyperpiesia or chronic glomerulo-nephritis.

In the second paper 2 A. B. Walter is concerned withan analysis of 205 cases of hyperpiesia met with inhis practice. Touching upon the etiology of hyper-piesia, he quotes Allbutt’s dictum that the strongestcausal factor is heredity, both racial and familial,citing in support of this the interesting case of female

1 Cleveland Quart., July, 1936, p. 222.2 Canad. Med. Assoc. Jour., July, 1936, p. 38.

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twins who, at the age of 63, showed an equal hyper-tension though one had lived an active and the other asedentary life. The commonest age of onset of hyper-piesia is not yet accurately known but Walter’s viewthat the bulk of it appears in the fifth decade tallieswith that of other observers. He finds no evidencethat the blood pressures of essential hypertensivesbecome progressively higher as time goes on and,

in his series, deaths from uraemia occurred in only2 per cent., the majority being cardiac or, less

commonly, cerebral. The importance of the diastolicpressure is rightly emphasised : 90 to 95 mm. Hgis given as the upper limit of normal accepted by amedical insurance institute. Walter would restrictthe use of the term hyperpiesia to those cases withraised diastolic pressures, though he does not specifywhat height of diastolic pressure he regards as

dangerous. It will be remembered that Allbutthimself looked with suspicion on diastolic pressuresof 90 mm. or over ; but nowadays figures a good dealhigher than that are generally considered compatiblewith long and active life.

A PREVENTIVE OF POLIOMYELITIS?

Simon Flexner has lately reaffirmed his conclusionthat " the only established portal of entry of thevirus of poliomyelitis into the central nervous systemof man is the nasal membrane, and especially theolfactory nervous areas in that membrane." Onthis basis Charles Armstrong and Walter G. Harrisonin America have inquired into the possibility of pre-venting the disease by spraying the nose with anantiseptic solution, and the United States publichealth service has thought it worth while to issue astatement describing the method. The spray at

present consists of a solution of equal parts (0-5 percent.) of picric acid and sodium alum in normal saline.At first it is used three or four times on alternate

days and later weekly, as long as the epidemic lasts.Enough of the solution is given for the spray to reachthe pharynx. The statement suggests that, since themethod has not yet passed the stage of experiments onmonkeys, it might be wise to await the results offurther trials before it is generally used in prophylaxis.

NERVOUS AND MENTAL SEQUELÆ OFCARBON MONOXIDE POISONING

IN this country carbon monoxide is by far thecommonest cause of fatal acute poisoning. Indeed,it outnumbers in its victims all the other poisonscombined. The same is true of the United Stateswhere, according to Martland,3 there are approximately500 deaths a week due to the gas. The subject istherefore of great importance. In non-fatal cases,the vast majority experience nothing worse than afew days of malaise ; a small proportion are debilitatedand inclined to be neurasthenic for several weeks ormonths ; and a very few suffer from serious nervousor mental sequelae. The truth of these facts is attestedby workers in widely separated countries. The most

thorough and informative of available recent studiesof the nervous and mental sequelae is that by Shillito,Drinker, and Shaughnessy.4 Other interesting papersare those of Christiani, Petersen,6 and Dancey andReed. 7 Of nervous sequele the commonest is a state

1 Jour. of Exper. Med., 1936, lxiii., 209. Included in Studiesfrom Rockefeller Inst. for Medical Research, vol. xcviii., p. 53.

2 Jour. Amer. Med. Assoc., August 1st, 1936, p. 363.3 Martland, H. S.: Jour. Amer. Med. Assoc., 1934, ciii., 643.

4 Shillito, F. H., Drinker, C. K., and Shaughnessy, T. J.: Ibid.,1936, cvi., 669.

5 Christiani, E.: Med. Welt, 1934, viii., 1469.6 Petersen, S.: Nord. med. tidsskr., 1935, x., 1507.

7 Dancey, T. E., and Reed, G. E.: Canad. Med. Assoc. Jour.,July, 1936, p. 47.

of more or less advanced parkinsonism. This isas might be expected, since various investigators haveshown in post-mortem investigations that the mostconspicuous changes are found in the basal ganglia.Hill and Semerak 8 found lenticular degenerationparticularly prominent in the brains of 32 patientswho had died after exposure to the gas. Sayers,Chornyak, and Yant also found gross changes in thecorpus striatum in experimental studies with dogs.At the same time, these latter investigators pointout that the damage caused by carbon monoxideis diffuse and may affect almost any part of the nervoussystem. Thus it is that, although parkinsonismmay be the most frequent complication, yet othervery varied neurological conditions have beenrecorded : sensory disturbances, such as skin anges-thesia and peripheral motor neuritis ; cerebralnerve palsies ; visual field defects ; various flaccidand spastic paralyses ; and sphincter disturbances.The commonest of the mental sequelae is a confusionalpsychosis with disorientation, lack of judgment, andamnesia. This state sometimes develops after a

period of one to three weeks of mental clarity, butgenerally it immediately follows the poisoning. The

psychosis is usually temporary and improvementoccurs in a few weeks or months, but in some casesit remains permanent. The mental disorder tendsto be combined with the nervous manifestations notedabove. Hallucinations and delusions have been

reported, but are much less common than simplebewilderment and loss of memory. It must againbe emphasised that serious nervous and mentalsequelae are rare, for of 81,659 admissions to NewYork mental hospitals only 39 were cases of psychosisdue to carbon monoxide.2 The chances of a patientdeveloping these complications depend ’mainly uponthe depth and duration of the poisoning. Most

patients who have suffered from them were gassedalmost to the point of death. Often the poisoningoccurred in the most unfavourable situations, suchas in suicidal attempts, in alcoholic intoxication, andin sleep. The impression that a period of unconscious-ness from a large dose of carbon monoxide characterisesthe acute poisoning in all instances in which after-effects are serious enough to bring the patient to amental hospital is substantiated by remarks appearingin the hospital records, such as " unconscious two

days," "unconscious four days."MEDICAL UNIT FOR SPAIN

THE first medical unit to be dispatched by theSpanish Medical Aid Committee leaves for Spain,via Paris, on Sunday next. Its director is Mr.K. W. C. Sinclair-Loutit, and the personnel includesfour surgeons, six nurses, eight" technical staff," andthree " quartermaster staff." The equipment issufficient for two operating theatres. The addressof the committee is Kern House, 36, Kingsway,London, W.C.2.

INDEX TO "THE LANCET," VOL. I., 1936

THE Index and Title-page of Vol. I., 1936, whichwas completed with the issue of June 27th, isnow ready. A copy will be sent gratis to sub-scribers on receipt of a post-card addressed to theManager of THE LANCET, 7, Adam-street, Adelphi,W.C.2. Subscribers who have not already indicatedtheir desire to receive Indexes regularly as publishedshould do so now.

8 Hill, E., and Semerak, C. B.: Jour. Amer. Med. Assoc.,1918, lxxxi., 644.

9 Sayers, R. R., Chornyak, J., and Yant,W. P. : Ibid., 1934,cii., 1800.