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ACTING FIRST ASSISTANT I N THE SURGICAL UNIT, ROYAL INFIRMARY, CARDIFFTHIS paper records an investigation into the nature and cause of swelling of the upper limb after radical mastectomy. The group of cases investigated has been previously reported by us (Devenish and Jessop, 1937) from the clinical aspect. These cases are characterized by the development of swelling of the upper limb after radical mastectomy in the absence of demonstrable recurrence. Observations were also made on patients recently subjected to this operation, and on some other patients. It will be convenient first to describe the methods employed and the results obtained in the present investigation, and subsequently to discuss their significance. NATURE OF THE SWELLINGEvidence of the nature of the swelling of the upper limb was obtained by three different methods-namely, clinical observation, radiographic appearance, and dye injection of the skin lymphatics.Clinical Observations.-Clinical observations showed that the swelling was always of two kinds, one pitting, the other not pitting. The usual assumption that pitting indicates the presence of cedema fluid was supported by observations on the shrinkage which occurred with continuous suspension of the limb.It was observed that on elevation of the limb shrinkage occurred most rapidly in the areas which pitted on pressure. Those areas which had been hard and non-pitting became, after varying periods of elevation, soft and pitted on pressure, but in no case was there a complete restoration to normal. There was always some residual swelling of a brawny indurated consistency, this being most marked in those parts of the limb swollen for the longest time. A distinction must be made between the hard non-pitting swelling present before treatment and the residual brawny indurated swelling left after long elevation of the limb. The former we believe to be due mainly to a high degree of tension of cedema fluid in the tissues, but the nature of the latter is obscure. It may partly be due to fibrosis of the subcutaneous tissue as the result of long-standing cedema, but the evidence available is inconclusive.Measurement of Shrinkage on Elevation.-The amount of shrinkage that followed elevation of the limb was estimated by displacement measurements of the volume of the limb. An arm bath filled to the brim with water was placed in a larger empty bath. The limb was then immersed in the full arm bath, and the volume of the water displaced into the outer bath measured. This was done three times and the average taken. Care was taken to see that the hand and forearm were fully immersed to the same skin mark each time.

A system of differential rapid maxillary expansion is described. This method is particularly useful in patients with cleft lip and palate who have severe defects of lateral maxillary growth, since it enables the maxillary segments to be rotated so that intercanine width increases without a concomitant increase in the intermolar width.