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muscle. To begin with the observer finds that he canintroduce an extraordinary large quantity of water-8 or 10 c.cm.-into the balloon inside the uterine cavitybefore he feels any resistance ... the uterus almostentirely loses its capacity for spontaneous contractionand becomes flaccid and sluggish."It will thus be seen that in his experiments duringthe luteal phase of the menstrual cycle Knaus musthave caused the uterine cavity to be distended to atleast two and a half times the capacity which Ifound necessary in my work. Dr. Reynolds’s criti-cism is thus not only negatived but actually reversed.

If, however, Dr. Reynolds wants to maintain thatin my work the uterus may have been locally dis-tended and irritated, I reply that the unalterablefact remains that the uterus in the second phase ofthe menstrual cycle is quite capable of powerfulcontractions if suitably stimulated ; and it was myobject in the address to show that increasinglypowerful contractions could be recorded in the lasttwo weeks of the cycle, which contractions finallymerge into those of menstruation (when the uterinecavity is again distended as by a foreign body).

Again, Dr. Reynolds’s suggestion offers no explana-tion of the fact that the uterus was found to respondto pituitrin (or vasopressin) at all stages of the cycle.Even if it can be shown that such a response is re-corded only by a certain technique, the fact that itis present in the human species considerably weakensthe value of the test for the date of human ovulation(refractoriness of the uterine muscle during theluteal phase to pituitrin) on which Knaus chieflybases his law of periodic fertility in the humanfemale. In my experiments the pituitary extracthas always been given intramuscularly in the usualclinical dosage. It has not been given intravenouslybecause of the increased risk of pituitary shock-acondition of not altogether rare occurrence, and,incidentally, one which may make the use of thecrude extract a danger rather than a help in casesof traumatic shock.

Finally, I hope that neither in the original addressnor in this letter has anything been said which

might be construed as belittling the value of Dr.

Reynolds’s admirable experimental work, or of the

equally outstanding and pioneering clinical investi-

gations of Knaus. It is my object, however, to showthat the matter is considerably more complicatedthan it appeared to be from the publications of theseworkers.-I am, Sir, yours faithfully,

CHASSAR MOIR.Obstetric Unit, University College Hospital, W.C.,

Dec. 31st, 1934.

HEALING OF TUBERCULOUS CAVITIES

To the Editor of THE LANCETSiR,-Your leading article of Dec. 15th under

this title gives much food for thought. The remark-able results which can be achieved by rest alone,provided it is sufficiently complete and sufficientlyprolonged, is perhaps not fully realised because theevil effects of the old adage about "going away forthree months " still persists. But that this state ofaffairs is not universal was demonstrated to me

during recent visits to sanatoria in Holland, where" graduated rest and exercise" has almost dis-

appeared, where the sanatoria grounds are deserted,but where the patients are kept in bed for nine ortwelve months, or longer if necessary. X ray photo-graphs showed almost miraculous disappearance of

huge cavities, some quite chronic, with no operativeinterference whatever. To the question, " but will

your patients stop that long in bed ? " one was met

by a tolerant smile. It is a matter of tradition and

’example ; in fact, patients sometimes protest whentold to get up, having been alarmed by relapseswitnessed in others who refused to continue with thestrict rest.On the other hand, visits to institutions in Scan-

dinavia, where operative collapse treatment is so

well developed, has convinced me that a note of

warning must be sounded with regard to the advicecontained in the statement : " If resolution is delayedor there is evidence of advancing disease artificial

pneumothorax should be undertaken, supplemented,if necessary, by section of adhesions or phrenic evulsionif cavitation persists" (my italics). Phrenic evulsion-i.e., an irrevocable measure, to be distinguishedfrom " phrenic crush " or the injection of alcoholinto the nerve-must be resorted to with greatcaution and in exceptional circumstances only,particularly in the cases referred to here, for it isin these very patients that partial thoracoplasty, anoperation giving excellent results in the hands ofsome people, may be indicated later. By performingphrenic evulsion one will have sacrificed the healthybase of the lung, jeopardising the success ofthe thoracoplasty, for an improvement generallyproblematical and at the most only transient.

I am, Sir, yours faithfully,Oslo, Norway, Dec. 24th, 1934. G. GREGORY KAYNE.

SERUM PROPHYLAXIS AND PUERPERALSEPSIS

To the Editor of THE LANCETSIR,—I am quite ready to agree with Dr. Colebrook.

Mrs. A, who died in three days from streptococcalinfection, and the mouse which died after injectionof a culture, both died for the same reason, and thatreason was not Dick toxin. I do not know whatresidual poisons are elaborated by streptococci whentoxin, if made (and many strains make little toxin),is neutralised ; and I emphatically agree that wewill make no great advance in the matter of strepto-coccal infection until we find out. But I am muchmore interested in Mrs. B : I think she exists, or

rather existed, since she too died ; and Dr. Colebrookdoes not. Mrs. B died in three days : she had tocontest not only with these residual poisons but alsowith toxin (the Dick erythrogenic toxin, certainly),and also with a complex group causing endothelialdamage, renal damage, gastric haemorrhages, red cellhaemolysis, inhibition of phagocytosis, and diffusionof organisms-a group all of which are neutralised

by antitoxin, but only when administered very early.Mrs. B had a double battle ; she might have wonagainst the residual factors, but succumbed to the laststraw, the toxic complex. That is my hypothesis.It is only a hypothesis as yet, and will remain oneuntil obstetricians are sufficiently convinced by theplausibility of the argument to give prophylacticserum an extensive trial. It may fail completely ;Dr. Colebrook may be entirely right ; streptococcaltoxin may be only a laboratory reagent, of no signifi-cance in human infection. Many women, unfor-tunately, will still die, even if I am right ; the residualfactors that kill the mouse will kill them. If we knewhow to neutralise them, prophylactic antitoxic serummight still have a value ; but it would be insignificantin comparison with that great discovery. Meanwhile,are we justified in neglecting a prophylactic methodbecause it is of limited efficacy °? Do we refuse to

put up an umbrella because it will not keep our

feet dry? -I am, Sir, yours faithfully,London, W., Dec. 31st, 1934. R. J. V. PULVERTAFT.

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