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"The force of elastic recoil of the lungs therefore measures thelimit of pressure fall in the pleural sacs which the thoracic".expansion can effect. If the lungs have but little elasticrecoil and stretch easily very little negative pressure can beproduced by the thorax on inspiration ; if the coefficient ofelasticity be great and the lungs have considerable elasticrecoil the inspiratory muscles expanding the thorax havesomething to pull against and can produce greater negativepressure; if the lungs be comparatively rigid the wholeforce of the inspiratory muscles can be directly expended onreducing the intrapleural pressure. In this sense Dr. Camp-bell’s contention seems to me physically correct.

On the other hand, there are conditions in which Sir JamesBarr is correct likewise. For consider the thorax and itsrespiratory muscles at rest. The lungs remain stretched;- they support by their elastic recoil a certain fraction ofatmospheric pressure to which the intrapleural space (ifspace it may be called) is not subjected in consequence.In that sense, as Sir James Barr states, there is a slightnegative pressure in the pleurae owing to the elasticity.-of the lungs." Why all new repair elastic substance inthe lungs is laid down in a stretched condition is dimou’tto see, though the utility of it is obvious. One would haveimagined that the elastic tissue would have arranged to beat rest when the thorax was at rest, but it strangely chooses,from birth onwards, never to assume the unstretched con-,dition. There is, therefore, a residual negative pressure forwhich the pleural sacs are indebted to the elasticity of thelungs and the opposing rigidity of the thorax. For the rest,the active and greater falls, they are indebted to the mus-cular efforts of the thorax and diaphragm and are distinctlosers by the comparatively low elastic recoil of the lungsthemselves. I am, Sir, yours faithfully,

Mentone, Jan. 16th, 1908. D. W. SAMWAYS.

BRITISH SHIP SURGEONS’ ASSOCIATION.To the -Editog- of THE LANCET. I

SIR,-May we through your valuable journal issue a letterof welcome to all members of the medical profession interestedin the formation of the above association ? A meeting hasbeen arranged to take place on Monday, Jan. 27th, at 8 P.M.,atthe Medical Graduates’ College and Polyclinic, 22, Cbenies-street, Gower-street, London, W., and we hope for a large andrepresentative gathering. The object of such an associationhas been given in former issues and ship surgeons are almostunanimous as to its need. As some of us from the north are

coming at great inconvenience to our practices we do hopethat ex-ship surgeons and others now practising in or near4he metropolis will do their best to attend.

I am. Sir. vours faithhllv.

...Jan. 20th, 1908.G. METCALFE SHARPE, Hon. Sec.,

Late Surgeon Cunard and P. and O. Companies.

LICENTIATES IN MIDWIFERY.To the Editor of THE LANCET".

Sm,-The annotation upon this subject in the current

I’’number of THE LANCET suggests that it would not beinopportune to relate.a stage in the history of medicalpolitics in this country, particularly with respect to the"education of would-be women medical practitioners: In 1852the Royal College of Surgeons of England sought and gainedin a supplementary charter power to examine "persons"for a diploma-Licentiate in Midwifery of the Royal College-of Surgeons of England, commonly abbreviated to " L M."It is said that the inclusive word "persons in Clause 17of the new charter was introduced deliberately. UnderSchedule A (4) of the Medical Act, 1858, such persons mightbe "registered" with this single qualification. It was, how-ever, urged by some that the ’’ L.M." diploma was only to beissued to men who were already otherwise qualified. TheMedical Act, 1875 sec. 2, did not vary the position. This

diploma was suppressed in 1876. In 1872 the King’s andQaeen’s Colleges (now the Royal College) of Physicians inIreland made their midwifery licence registrable ; in 1874they granted diplomas to midwives. It was not, of course,until the Medical Act, 1886, sec. 2, became law that a triple.,qualification in medicine, surgery, and midwifery was-essential prior to the registration of the name of a would-beonedical practitioner. I

The Female Medical Society (1862-72) was founded "to

provide educated women with proper facilities for learningthe theory and practice of midwifery and the accessorybranches of medical science." The Ladies’ ObstetricalCollege (Great Portland-street) was founded in 1873. In1875 Miss Sophia Jex-Blake, Miss Edith Pechey, and Mrs.Thorne, having been informed of an opinion of counsel givento the College of Surgeons as to the scope of Clause 17 oftheir enlarged charter, and having fulfilled all precedentrequirements, claimed to be "persons" who must be exa-mined by the Royal College of Surgeons for the licence in mid-wifery. In this way they hoped to secure admission to theMedical Register. The midwifery board of examiners of theCollege, led by the late Dr. Robert Barnes, resigned in protest,thus postponing in January, 1876, the examination sine die.It has never since been conducted. The Obstetrical Society ofLondon concurred with this practical protest. The late Dr.Robert Barnes, writing to me in October, 1906, said withrespect to this incident: "I I may say that 1 rescued the

College and the profession from the disgrace of issuing abarren midwifery licence."

I am, Sir, yours faithfully,Adelphi-terrace, W.C., Jan. 13th, 1908. STANLEY B. ATKINSON.

A CASE OF "DIPHTHERIA OF THE SKIN."To the Editor of THE LANCET.

SIR,-Dr. J. G. Hare is to be congratulated in clearing upthe nature of Dr. Alan B. Slater’s remarkable case of cuta-neous diphtheria as reported in THE LANCET of Jan. 4th. Thecase raises some interesting pathological issues, particularlyin regard to the underlying cause of a diphtherial infectionso extensive. It is, however, perhaps unnecessary to infersuch an unusual course of events as that suggested by Dr.Slater in his ingenious explanation. Diphtheria bacilli donot spread far and wide riâ the superficial lymphatics, butthey are conveyed at times from one abraded surface toanother by auto-inoculation. Moreover, while neuritis is anordinary and specific feature of diphtheria, herpes of theneuritic type is rare in that disease-is, in fact, commonerin other infections, notably scarlet fever, which present therash as a pure complication.The peculiar characteristics of the case being the wide-

spread distribution of the lesions and their long duration, itseems to me that if auto-inoculation be accepted an explana-tion based on established pathological facts is forthcoming. Itis well known that nurses with slight abrasions of the fingersmay, when working in diphtheria wards, develop a localiseddiphtherial infection and that a permanent cure may not beobtained for weeks or even months if antitoxin is not given.It may happen that more than one finger is infected, andthere seems to be no reason why this modified form ofdiphtherial lesion should be restricted in distribution wherethe inoculable points are multiple. Given, then, that theoriginal conjunctivitis and vulvitis were wholly or partlyseptic in nature, it might well be that the patient developeda spreading septic rash such as is often seen under such con-ditions in children. The cutaneous abrasions would offer

points of inoculation, and the diphtheria bacillus, establishedanywhere from mixed infection of the eye or vulva or froman outside source, would be readily carried in the dischargesfrom one area to another.Now that Dr. Hare has proved bacteriologically the nature

of one case, there is the interesting possibility that otherobstinate skin affections of a similar type may also tura outto be diphtherial.

I am, Sir, yours faithfally,JOHN BIERNACKI.

Plaistow Hospital, London, E., Jan. 12th, 1908.

ACUTE PULMONARY ŒDEMA.To tke Editor of THE LANCET.

SIR,-With reference to the interest lately awakened bythe able dissertation upon acute pulmonary oedema by Dr.Leonard Williams in THE LAKCET of Dec. 7th, 1907, may Ibe permitted to add my humble testimony of what I considerto be a most remarkable and typical example of the con-dition. At 10 P.M. last night I was summoned to see a manwho, I was told, had been taken suddenly and severely ill. I

immediately set out and arrived on the scene within fiveminutes of the summons to find the patient dead.The history was as follows. The patient, a man, aged

48 years, had been at his work all day apparently in the best

262

of health excepting a slight dry cough from which he hadbeen suffering for the past week or ten days. He returnedhome a little after 6 P M. and partook of his usual tea, imaking a good supper a little before 9 previous to turning infor the night at about 9 30 P.M., as from the nature of hisoccupation he was obliged to keep early hours. At a fewminutes to 10 he started out of bed, remarking to his wifethat he "felt choked" and ran into the front sitting-room. Here he sank on to a chair and evidently still

experiencing intense agony in this situation rolled on tothe floor and expired. His intensely cyanosed appearanceon rising out of bed so alarmed his wife that I was sentfor immediately and arrived at the house it is estimatedless than ten minutes after the time when he left hisbed. The remarkable severity and rapid dissolution inthis case call, I think, for special notice as the experiencemust be a very rare one. The appearance of the body whenfirst seen by me was as follows. The face was intenselylivid and wore an expression of agony, the pupils were verywidely dilated, the body was of a natural warmth, supple,muscular, and well nourished and the thorax well formed.Even at this time an abundance of white foam was wellingfrom the mouth and nostrils and there was an escape of aconsiderable amount of pinkish serous fluid from themonth. I made the necropsy to-day at 3 P.M., at whichthe following additional appearances were observed.Post-mortem lividity was strongly marked and the veinsall over the surface of the body were greatly distendedwith very dark blood. The frothy material was still

issuing from the nostrils and mouth but the flow of serousfluid had ceased. Ktch pleural cavity contained about halfa pint of reddish serous fluid. The lungs were somewhatvoluminous from commencing emphysema at the apex andanterior borders and on division of the bronchi discharged anenormous quantity, over three pints, of reddish serous andfrothy fluid, while this could also be squeezed from the lungthrough the bronchi and all cut surfaces in abundance, thelung tissue then assuming a vesicular character. The largerbronchi and trachea were clear but somewhat congested andotherwise the lung tissue appeared normal. The left tventricle was markedly hypertrophied, the heart weighing19 ounces, and the aortic valves were somewhat thickened,distorted, and incompetent. The other valves were appa-rently normal. The aorta was the seat of well-marked athe-romatous changes, while the radial and temporal arteriesalso manifested pronounced thickening and tortuosity.The other organs of the body were in an apparently healthycondition. Microscopically no characteristic abnormal ap-pearance can be detected in the lung. The patient had notbeen under any treatment. No history of heart or kidneytrouble could be obtained. I expressed the opinion thatdeath was due to the sudden strain thrown upon the heartby the rapid engorgement of the lungs.

I am, Sir, yours faithfully,G. H. C. LUMSDEN, M.B. Aberd.Brighton, Jan. 17th, 1908.

2’0 the Editor of THE LANCET.

SIR,-In Zola’s powerful book " F6oondit6 there is a

graphic description of the sudden illness of a perfectlyhealthy young woman whose symptoms began at bedtime,following a wetting from a rain-storm in the afternoon, andwho died after intense suffering at 7 o’clock in the morning,"d’une congestion puimonaire." " When the book was pub-lished eight years ago a medical friend discussed this casewith me. As neither of us was familiar with an acute

pneumonia or pulmonary congestion which would cause

death in a hitherto healthy adult within seven or eight hourswe were at first inclined to class this description among theerrors of novelists writing on subjects of which they areignorant ; remembering, however, the notorious accuracy ofM. Zola and the mastery of technical detail which he alwaysacquired of any subject on which he undertook to write, andhaving, moreover, both been in practice sufficiently long tohave learnt that we did not know everything, we decidedthat the novelist was probably correct and our own limitedexperience at fault.

I now learn that the case described corresponds accuratelywith those cases of rapidly fatal " acute pulmonary cedema

"

which have recently been recorded by correspondents in yourcolumns. The clinical picture of the illness drawn byM. Zola is most vivid and accurate and is to he found onpp. 557 to 559 of the ordinary French edition. Perhaps thedisease is better known in France than in England, for M.

Zola writes of it as of something not very uncommon.Themedical interest, in other respects, of this striking book issuch, and the moral it teaches so impressive, that all might-read it with advantage. I am, Sir, yours faithfully,Jan. llth, 1908. C. K.

THE SOCIETY OF MEDICALPHONOGRAPHERS.

l’o the Editor of THE LANCET.

SIR,-It is many years since the Society of Medical’

Phonographers was last mentioned in your columns and weshall be glad if you will allow us to direct attention to thefact that it still exists and still issues its medical periodicalin lithographed phonetic shorthand. We believe that manystudents and members of the profession are ignorant of thesociety and its efforts to promote the effective use of short-hand in medicine, both in practical work and in research.The honorary secretary will be glad to furnish particulars ofthe society to any members of the profession or studentswho may desire to join it.

We are, Sir, yours faithfully,

January, 1908.

WILLIAM R. GOWERS, President.CHARLES W. CATHCART, Vice-Presidents.G. SIMS WOODHEAD,OSKAR C. GRUNER, Honorary Secretary,

Pathological Department, GeneralInfirmary, Leeds.

THE CAUSE OF THE PREVALENCE OFADENOIDS.

To the Editor of THE LANCET.SIR,-If reliable statistics were available it would,

believe, be conclusively proved that during the last 30 yearsthere has been a remarkable increase in the number ofchildren affected with adenoids. That adenoids have alwaysexisted may, no doubt, be correctly inferred from indirectevidence, but on the other hand, evidence has been brought-forward to show that until recent years it must have beenquite a rare disease. However, as regards what exists at.present, I would mention that it is difficult to find evi-dence of many cases indicating the previous existence ofadenoids among people of 40 years of age and upwards,whereas it seems to be comparatively rare to find a familyof children without at least one of its members havingsuftered from the disease. It is not my intention, however,to compare the past with the present. What I want to dois simply to state that without any attempt at selection Itook a number of families whose habits I knew with

regard to the keeping of open windows in the sleepingapartments of their children. Of those who kept the windowsshut at night there were five families, having 26 children inall, and not one of these 26 children had ever saff ered fromadenoids. While of five families, having 19 children in all,who kept open windows at night throughout the year, eightof these children had suffered from adenoids sufficientlybadly to have required operation. Now I do not put anyimportance on these figures, they are too few to be of anyparticular value beyond being very suggestive, and it wasnot on account of them that I was led to think that openwindows at night might be an important factor in thecausation of the prevalence of the disease. I am writingbecause I am not in a position to get as full statistics on thesubject as seems desirable and I should like particularly toknow the effect of cold and damp night air, such as weusually have in England, in the production of adenoids andof its value or otherwise in the treatment of an ordinarycold in the head.

I am, Sir, yours faithfully,- ---

Wimpole-street, W., Jan. 20th, 1938. J. SIM WALLACE.

THE INFECTIVITY OF CANCER.To the Editor of THE LANCET.

SIR,-I very much regret to find from his letter addressedto you in THE LANCET of Jan. 18th, p. 188, that I have in-

advertently misrepresented Dr. Bashford by attributing tohim instead of to Messrs. Farmer, Moore, and Walker thestatement reported in the British Medical Journal ofJan. 30th, 1904, that "malignant new growths were virtuallyreproductive tissue arising in abnormal situations " and I am