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up the limb are left unansesthetised. By this methodScott and Morton find it easy to assess the degree towhich the vascular obstruction will be relieved bysympathectomy and thus to choose their cases

for operation with more success. P. G. Flothow 2

has obtained similar results, but he prefers to injectthe sympathetic ganglia supplying the affected partwith a local ansesthetic. By this method he claimsthat not only are all the sympathetic fibres eliminatedbut that also the degree to which pain will be relievedby operation may be prejudged. It is stated thatthe technique of these injections is simple and thatthey cause little discomfort.

REGENERATION OF THE UTERINE MUCOSA

AFTER DELIVERY.

THE involution of the puerperal uterus is one ofthe most remarkable processes met with in the

body. It leads in the short space of six weeks to thereduction in size of the uterus from that of an

abdominal tumour extending nearly to the level ofthe umbilicus at the end of the third stage of labourto dimensions which differ very little from those ofthe virgin uterus. The process is of necessity complexand much of it is but little understood. Histologicalinvestigations are handicapped by scarcity of material,for it is only rarely that uninfected specimens areobtained. The involution of the muscle-fibresconsists of a granular atrophy without fatty degenera-tion and there is no evidence that individual fibresare absorbed. The involution of the vessels isdifficult to interpret, and at the present time thecontradictory views of Goodall 3 and Wilfred Shaw 4are disputed. More is known of the regeneration ofthe mucous membrane of the uterus, for Teacher’sl 5

contribution in 1927 cleared up some of the difficulties.The late Prof. Whitridge Williams 6 shortly before hisdeath called attention to the involution of the

placental site and based his views upon the study ofeighteen uninfected puerperal uteri. It is well knownthat the placental site is sometimes difficult to

identify immediately after delivery, but within a

few hours, probably owing to the relaxation of theuterus, its sinuses become engorged with blood.The sinuses become thrombosed and are then readilyrecognised by their vascularity ; moreover the

placental site projects above the general surface ofthe lining membrane of the uterus. Involution ofthe placental site proceeds until by the end of thesixth week after delivery the endometrium lines themucous membrane of the uterus completely, andmacroscopical examination reveals little trace of thesituation of the placental site. The mechanism ofthe renovation of the rest of the endometrium isrelatively simple. The line of cleavage between themembranes and the uterus is through the spongylayer of the decidua, and after expulsion of the placentaand membranes a raw area remains which oozes

blood and serum. The superficial part of this zonebecomes infiltrated with leucocytes, and by necrosisthe remnants of the spongy layer are shed to formpart of the lochial discharge. The cells of the basallayer of the glands then grow over the denudedarea in a way which is comparable to the processof repair after menstruation. The most strikingfeature of the renovation is its rapidity, and

2 Amer. Jour. of Surg., December, 1931, p. 591.3 Goodall, J. R.: Studies from Royal Victoria Hospital,

Montreal, 1910, ii., No. 3.4Shaw, Wilfred : Jour. Obst. Gyn. Brit. Emp., 1929, xxxvi., 1.

5 Teacher, J. H. : Ibid., 1927, xxxiv., 1.6 Williams, Whitridge : Amer. Jour. Obst. Gyn., 1931, xxii.,

664.

Whitridge Williams was able to confirm the acceptedview that involution of this part of the endometriumis completed by the third week of the puerperium.The involution of the placental site zone is, as mightbe expected, much more intricate, and six weekselapse before the placental site is covered by endo-metrium. Whitridge Williams showed that leucocyticinfiltration and necrosis can be demonstrated in thesuperficial layers in the first two weeks of the

puerperium, and that this zone is shed in a waysimilar to that obtaining over the rest of the endo-metrium. The thrombosed sinuses and vessels

develop hyaline tissue in their walls and are

reduced in size partly by subendothelial proliferationand partly by absorption of the hyaline tissue. Themain point of Whitridge Williams’s thesis is thatthe bulk of the placental site is actually exfoliatedduring the fourth and fifth weeks of the puerperium.Exfoliation is produced as a result of the activityof the adjacent endometrium which undermines theplacental site and detaches it from the wall of theuterus. This mechanism is assisted by the hyper-trophy of the fragments of the basal layer of theendometrium which lie between the placental siteand the wall of the uterus. The evidence which is

brought forward is fairly convincing, and the onlydifficulty in accepting the explanation is that thereis not a characteristic uterine discharge at this phaseof the puerperium. It is interesting to notice thatthe only previous observations on the puerperaluterus which suggest a similar mechanism are thoseof Ries which were published some forty years ago.The histology of the involution of the puerperaluterus is worth further study.

CARDIOLOGICAL DIAGNOSIS.Two useful pamphlets have recently been pub-

lished by the heart committee of the New YorkTuberculosis and Health Association. They dealwith the criteria for the interpretation of electro-

cardiograms, and -with radiological diagnosis in heartdisease. One of the principal objects of the Associa-tion is to achieve a standard nomenclature and there-

by render comparable the results obtained by differentworkers. Such uniformity would also facilitate thestudy of cardiological problems from the statisticalaspect. In the pamphlet dealing with electro-

cardiography 50 variations in the form of the record aredescribed. Of these, 27 are concerned with the heart’srhythm, three with deviation of the electrical axis,and the remainder with the form of the differentdeflexions which constitute the auricular and ven-tricular complexes. The list of phenomena consideredincludes all the common deviations from the normal,and the only feature which might, perhaps, be

regarded as an unnecessary refinement is the sub-division of the duration of the Q R S complex intothree (short, medium, and long) instead of the usualtwo types (less than and greater than 0-1 sec.). The

pamphlet is illustrated by a series of typical records.The pamphlet on Radiologic Diagnosis in HeartDisease opens with a simple and lucid account of themethods of procedure. It then deals with the diag-nosis of enlargement of the various cardiac chambersand of the aorta, stress being laid on the fact that itis much more important to ascertain which chambers ofthe heart are involved rather than to obtain an exactmeasurement of the size of the whole heart. In placeof actual radiograms a series of 31 line diagrams are1 Criteria for the Interpretation of Electrocardiograms.Guide to Radiologic Diagnosis in Heart Disease. New YorkTuberculosis and Health Association. 1931.

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given. These serve to illustrate clearly the variousfeatures described in the text. In the prefaceDr. Alfred E. Cohn points out that this is

merely a tentative effort at classification, and neces-sarily incomplete ; but that the authors are

to be congratulated on producing such a helpfulintroduction to a difficult subject.

THE TREATMENT OF PRURITUS SENILIS.

THE aetiology of pruritus senilis is frequently obscure.It is not an uncommon symptom, and is one of themost lamentable and intractable of the penalties ofold age. The hypothesis of essential skin changesof a degenerative type, with loss of elastic fibres, isno longer tenable, for the large majority of individualswith senile atrophic skin do not have pruritis. It isessential in every case to exclude such obviouscauses as pediculi, cystitis with an enlarged prostate,strictures, and latent carcinoma, especially of theliver. Dr. H. Abelson,l of Leipzig, believes he hasestablished another factor in a metabolic under-nourishment of the cutis due to senile changes in itscirculation-i.e., a cutaneous arterio-sclerosis. For

many years he has always given iodine to such

patients with benefit, and for the last six months hasobtained encouraging results with a skeletal muscleextract-lacarnol. This drug-the main indicationfor which is angina-is quite harmless, and is pre-scribed in drop doses on sugar, up to 12 or 15 dropst.d.s. In eight of Abelson’s cases there was so muchimprovement in a week that the patients are statedto have forgotten to apply local antipruritics. Furtherbenefit was obtained by 1 c.cm. injections hypodermi-cally twice a week. This group of cases and threemore were completely cured of itching in four weeks,but in a third group of 12 cases this happy resultwas not secured, and the patients had to continueto seek relief by local measures after a six weeks’trial of lacarnol. The element of suggestion cannoteasily be excluded, especially in such a small seriesof cases, but the good results in nearly half the casessuggest a trial of this method.

PRIMARY CARCINOMA OF THE LUNG.

THE recent increase in the number of cases of

primary carcinoma of the lung may not be real, butcertainly more cases are being reported. Dr. B. M.

Fried, in a clinical and pathological study,2 states hisopinion that the increase is due to more accurate

diagnosis, the fact that attention has been focused onthe condition, and an increase in the span of humanlife. Though this is a comforting suggestion, autopsyreports from the large hospitals cannot be ignored.James Maxwell from London, J. B. Duguid fromManchester, W. Kikuth from Germany, and C. V.Weller from America, and other workers report adefinite and steady increase in the percentage ofcarcinomata of the lung seen at autopsies, and alsoan increased proportion in relation to the totalnumber of malignant growths. Maxwell notes that"the thorax is assuming increasing importance as aprimary site of malignant disease." Dr. Fried reviewsagain the possible setiological factors that have beenblamed, such as influenza, tarred roads, tuberculosis,syphilis, and trauma, but has to reject each in turn.If more space in the literature on bronchial carcinomawere given to diagnosis, especially early diagnosis, andless on histogenesis and metastases, the average

1 Dermat. Woch., 1931, xciii., 1775.2Medicine, 1931, x., 373.

medical reader would be grateful. Dr. Fried is notvery helpful in this respect, but he does add one newidea of importance. He suggests that bronchialcarcinoma frequently runs a protracted course, oftenof several years’ duration, during which time thepatient’s symptoms suggest only a mild inflammatorydisease of the bronchi. In Dr. Fried’s view, prac-titioners are so oosessed witti tile terminal picture orthis disease as seen in the post-mortem room thatthey are inclined to forget the onset : that two yearsbefore their patient started having bronchitisand that his sputum was occasionally streakedwith blood. The difficulty facing the practitioner isthat if he is to make an early diagnosis he mustsubject the patient to special examination, such asbronchoscopy and X rays, at a time when the com-plaint is only of what may appear trivial pulmonarysymptoms. To wait nowadays for physical signs todevelop before making a diagnosis of pulmonarytuberculosis is to deny to the patient the best chanceof recovery ; and this is true, also, of pulmonarycancer.

Directly opposed to the theories of Dr. Fried arethose of Dr. Jacob Polevski.3 He maintains that

primary cancer of the lung can be diagnosed clinicallyby the characteristic history and physical signs, thatfluoroscopy is of great aid in doubtful cases, but thatbronchoscopy and biopsy are rarely necessary. This.

expectant attitude can hardly be justified, since

progress cannot be anticipated unless active steps aretaken to ensure early diagnosis. Dr. Polevski reportsnine cases, all of which showed on the X ray a shadowextending out to the periphery of the lung. This is,unfortunately, the stage at the time many patientsseek advice, but the absence of such pronounced signsby no means excludes cancer. Primary cancer of thelung originates in the bronchial mucosa near or

around the hilum of the lung. X rays will not showany abnormal shadow until the growth has spread intothe surrounding tissue, or, what is more frequent, hasgrown into and obstructed the lumen of the bronchus,causing atelectasis and pneumonitis in the obstructedarea of the lung. It is only with the bronchoscopethat we can hope to see the beginnings of this disease.Chevalier Jackson has so popularised bronchoscopy inthe United States that the practitioner does nothesitate to recommend it to his patient any more thanhe would hesitate to advise cystoscopy in an obscurecase of hoematuria. More bronchoscopic clinics areneeded in England, though it must be confessed thateven with an early diagnosis the outlook is still gloomy.X ray therapy can offer only palliative treatment,while radium and partial pneumectomy are still inthe experimental stage. The results of these are

sufficiently encouraging to offer at least a slight

hope for the future. ____

HEALTH OF THE ARMY IN 1930.

THE report 4 on the health of the Army in 1930,signed by Lt.-Gen. Sir H. B. Fawcus, Director-General, Army Medical Services, registers furtheradvances in the struggle for scientific recognition,treatment, and prevention of disease in the Army.The report is concerned with 10,972 officers and178,384 other ranks. The figures of illness which itrecords are nearly all lower this year, probablybecause there was no considerable outbreak ofinfluenza in 1930. The admissions to hospital perthousand were 428-4 (468-5 in 1929), deaths 2.32 (2-45),finally invalided 9-28 (10-1), and constantly sick

3 Arch. Intern. Med., 1931, xlviii., 1126.4 H.M. Stationery Office, 1932, pp. 151, 2s. 6d.