1211

If the changes recorded by the electrohysterograph arenot due to uterine contractions per se, to what do theyowe their origin Halliday and Heyns suggest that theymay be related to the chemical changes associated withanoxia, but anoxia is often present when there is no

progressive labour. Alternative explanations are : (a)that they are due to a pain reflex (conscious or uncon-scious) with vasomotor changes in the skin ; (b) thatthey are of uterine origin and are present in the skin insufficient intensity for measurement only with verystrong contractions ; (c) that they reflect uterine retrac-tion, about which little is known. When more has beenlearnt about the cause of these changes the electro-

hysterograph may win a place in the diagnostic routineof the labour ward.

1. Mann, T. P. Lancet, March 19, 1955, p. 613.2. Ashton, N., Ward, B., Serpell, G. Brit. J. Ophthal. 1953, 37, 513.

See Lancet, 1954, i, 86 ; Ibid, 1954, ii, 275.3. Kahn, E., Walker, A. R. P. Pediatrics, 1954, 14, 659.4. Clark, R., Quin, J. I. Onderstepoort J. vet. Sci. 1947, 21, 317.5. Bower, B. D. Quart. J. Med. 1954, 23, 218.

THE INFANT’S PHYSICAL ENVIRONMENTTHERE is still much uncertainty about the optimum

environment for the young infant and his response toeither hypothermia 1 or over-heating. This uncertaintyis particularly great in the case of prematurity. Hereanimal research is of limited value, since immatureanimals almost invariably succumb. But in their brilliantwork on retrolental fibroplasia Ashton and his colleagues 2made use of the relative immaturity of the newbornkitten’s eye to demonstrate the effects of exposure to

high oxygen concentration. In studying the very youngthe veterinary surgeon, with larger litters and quickturnover, has many advantages over his paediatrictolleague; and his observations often have. a bearingon problems of infant management.The neonate can undoubtedly withstand a degree of

anoxia that would be lethal to an older child ; and this,together with his surprising resilience after surgicaloperation, has led to a change in outlook. Whereas our

predecessors literally wrapped him in cotton-wool, thenew generation tends to believe that he can stand almostanything. But his survival does not necessarily meanthat he has passed through an experience unscathed..

Kahn and Walker,3 studying African infants, showedthat sweat secretion was impaired in those with malnu-trition, and that in hot weather this impairment mightbe associated with fever. They exposed infants withkwashiorkor, and healthy controls, to conditions of heatand humidity such as are found in the poorer Africandwellings in hot weather, and determined the responseof the sweat-glands quantitatively. In the malnourishedbabies the degree of cedema was not strictly related todiminution of sweating, but their ability to secrete sweatreturned with improved nutrition. The findings of Kahnand Walker are supported by the veterinary experimentsof Clark and Quin,4 who studied the heat-regulatingmechanism in merino sheep. They found that foodintake had a direct effect on the sheep’s ability tomaintain body-temperature during exposure to cold.

Response to hot environment also depended largely ongeneral body condition ; thin sheep on a poor dietshowed suppressed panting reflex and excessive rise intemperature. Bower,5 studying the peripheral vaso-

motor control in healthy children, showed that even innormal full-term neonates the rise in skin-temperature inthe other limbs on immersion of one limb in hot waterfollowed a curve different from that obtained with normalinfants over three months of age. In the very youngbaby the response was much more sluggish, and inalmost every case the maximum skin-temperaturewas lower.These reports teach a useful lesson-namely, that the

neonate is delivered to us at body-temperature but is

handicapped by poor vasomotor response and a relatively

large surface-area. If he is premature these handicapsare exaggerated. With satisfactory feeding, each daythat passes sees further adjustment to the new environ-ment ; but even in later infancy the relative instabilityof the young child may be made evident again by illness,infection, or malnutrition.

1. Effler, D. B., Blades, B., Marks, E. Surgery, 1948, 24, 917.2. O’Brien, E. J., Tuttle, W. M., Ferkaney, J. E. Surg. Clin. N.

Amer. 1948, 28, 1313.3. Bugden, W. F. Amer. Rev. Tuberc. 1950, 62, 512.4. Davis, E. W., Klepser, R. G. Surg. Clin. N. Amer. 1950,

30. 1707.5. Sharp, D. V., Kinsella, T. J. Minnesota Med. 1950, 33, 886.6. Abeles, H., Ehrlich, D. New Engl. J. Med. 1951, 244, 85.7. Effler, D. B. Amer. Rev. Tuberc. 1951, 63, 252.8. Harrington, S. W. Dis. Chest, 1951, 19, 255.9. Hood, R. T. jun., Good, C. A., Clagett, O. T., McDonald, J. R.

J. Amer. med. Ass. 1953, 152, 1185.10. Storey, C. F., Grant, R. A., Rothmann, B. F. Surg. Gynec.

Obstet. 1953, 97, 95.11. Wilkins. E. W. New Engl. J. Med. 1955, 252, 515.

THE SOLITARY PULMONARY NODULE

THE widespread use of chest radiography has led toincreased interest in the isolated pulmonary noduleunassociated with symptoms 1-10 and Wilkins 11 has nowanalysed a series of 77 such cases. 27 proved to beprimary pulmonary carcinomas, 6 metastatic carcinomas,18 tuberculous lesions, 21 benign tumours or cysts, and5 inflammatory processes of various kinds.

When an isolated nodule is found the pressing questionis whether it is a primary pulmonary carcinoma, because,if it is, delay in diagnosis may cast away the possiblechance of survival offered by resection. In patientsbelow the age of 30 carcinoma is unlikely ; the chancesincrease with advancing years, and in Wilkins’s series50% of the lesions in patients over 50 years were provedto be malignant. Tuberculosis is commoner in youngerpatients, but is by no means rare even in the aged.Simple cysts and tumours may also be discovered atany age, and, although some of them have favourite loca-tions in the lung-fields, this is an uncertain guide becausecarcinoma may originate in any site. Areas of calcificationin the lesion (sometimes demonstrable only by tomo-graphy) suggest a tuberculoma or hamartoma, but acarcinoma may arise in or near a calcified scar. Such

generalisations are, therefore, of limited diagnosticvalue, and a more direct approach is often equallyunrewarding. The lesion is usually beyond broncho-scopic vision, and the finding of no tubercle bacilli orcancer cells in the sputum and bronchial secretions doesnot help in diagnosis. If the lesion is near the pleuraaspiration biopsy may seem the easiest way of resolvingdoubt ; but this investigation is best avoided becauseof the danger of implanting malignant cells in theneedle track. Inquiry regarding previous radiographicexamination of the chest may be more rewarding thanelaborate investigations ; for the recent appearance of a

lesion-particularly in an elderly man-has a sinister

significance. In the majority of cases exploratorythoracotomy is necessary for exact diagnosis ; and,since the risk is trifling compared with the danger oftemporising with a possible bronchial carcinoma, Wilkinsand all others with experience in the subject urge thatthis operation should be done without delay. Naked-eyeinspection of the nodule or examination of frozen sectionswill determine its nature, and thus the extent of opera-tion. Even if the lesion turns out to be non-malignant,most would agree that it will have been " nane the wauro’ a hangin’," although many would nowadays besatisfied with probation for a tuberculoma in a youngpatient.

Mr. GEOFFREY KEYNES and Sir LIONEL WHITBY havebeen appointed Sims Commonwealth travelling pro-fessors for 1956. Mr. Keynes will visit Canada and partsof Africa, and Sir Lionel Whitby Australia and NewZealand.