- Email: [email protected]
PARAPHRENIA.
735 The two first
are already in being organised. 7. The Central Committee has published in 1918 a special report on " Improvement of the Conditions of Childbirth in India " and in 1919 a report on " Venereal Diseases among
ment
of venereal diseases.
working order, the third is
agree with him. Certain it is that the matter cannot be settled by an invocation to Dr. Wharton Hood. I am old enough to remember that during his lifetime Dr. Wharton Hood was looked upon as hardly respectable. He wrote a large book in two volumes, a book almost forgotten. I should be surprised to hear that its precepts ever became a recognised basis of practice. I am, Sir, yours faithfully,
now
Women in India." This last contained confidential information, and was therefore circulated privately only. It must be remembered that the Central Committee has only had a subsidy of 10.000 a year for the Women’s Medical Service, and that owing to the demand for medical women in the war it has had extreme difficulty in keeping the service,up to strength. I am, Sir, yours faithfully,
-
1’0
M. I. BALFOUR, M.B., C.M.,
* ** Dr. Balfour has misread the title of our article, which dealt generally with the medical service of in India. With regard to our use of Dr. Wickham’s report, in the main report, which Dr. Balfour signs, it is stated: "The Central Committee from the many inspection reports in its own office can fully endorse the remarks made by Dr. Wickham and Dr. Scott, which apply to practically every part of India.’’ Our criticisms were directed, not against the Women’s Medical Service of India, or the work of the Lady Dufferin Fund, but against the difficulties under which they are placed. And it was our appreciation of these difficulties that prompted the plea for a State Service of women with conditions of local prestige, pay, and leave more nearly approaching those of the Indian Medical Service. Should such a change come about we have no doubt that the Government of India would avail itself of the extensive organisation of the Lady Dufferin Fund.-ED. L. women
I
MYALGIC PAINS AND MANIPULATION. To the Editor of THE LANCET. SIR.-With regard to Mr. R. C. Elmslie’s letter on this subject in your issue of to-day’s date, I am only too conscious of the assistance given to me by Mr. Elmslie himself, and other orthopaedic surgeons in the treatment of cases, to be in anyway unmindful of my obligations towards them-their special skill and ability are not questioned. The point is whether there is anything to be learned outside the ranks of the profession. Unless I am mistaken, an offer was made to demonstrate cases before a committee of surgeons; had this offer been accepted the whole matter would have been settled.-I am Sir, yours faithfully, W. H. CLAYTON-GREENE. Vimpote-street, BV., March 20th, 1920.
I
THE LANCET.
under this heading has wandered wide since its opening. Mr. E. C. Elmslie, in your issue of March 20th, endeavours to show the fallacy of the " myth " that a bone-setter possesses some mechanical skill denied to the regular surgeon, or, at any rate, to the regular orthopaedic surgeon. But with all respect I submit that a fallacy cannot be Mr. demonstrated by begging the whole question. Elmslie first gives the simple rules which govern the practice of the bone-setter. They are only two : first, restore mobility; second, restore the muscular power. Then he says : "Patients with derangement of the knee- , joint should only be submitted to operation when continued locking of the joint takes place in spite of the fact that mobility is full and the muscles strong." I I entirely misconceive the issues, unless I am right in believing that cases of this kind are precisely the cases that bone-setters profess to cure, and further, I, and many more of my profession, believe that we have personal knowledge of cases within this category which bone-setters actually have cured. Yet Mr. Elmslie says
I
operation only. Mr. Haldin Davis thinks that it is consonant with the dignity of the Royal College of Surgeons to appoint a committee of investigation to see if the case is as extremely simple as Mr. Elmslie suggests. I entirely
in your issue
March 20th, with which I entirely agree, will serve a I of useful purpose if it leads to some understanding as to
Delhi, Dec. 24th, 1919.
of SIR,-The correspondence
ANÆSTHETISTS’ FEES. the Editor of THE LANCET.
SIR,—Mr. H. Bellamy Gardner’s letter
Joint Secretary, Countess of Dufferin’s Fund.
To the Editoq,
C. G. HAVELL.
Felixstowe, March 22nd, 1920.
what fees special anaesthetists should now be entitled to charge. If it is admitted that their pre-war scale of fees was not excessive, it is obvious that the same rate of payment must be totally inadequate now, in view of the enormous increase in the cost of living. The practice of anaesthetics as a specialty has an appreciable influence upon surgical results, and it is in the public interest that the fees of a whole-time anoesthetist should be sufficiently generous for him to earn a good living. Unless it is recognised that this is impossible on the pre-war scale, specialism in anaesthesia will gradually be starved out of existence. In most districts general practitioners have met and agreed to raise their fees in some definite ratio. Why should anaesthetists not do likewise ? I am, Sir, yours faithfully, J. HENRY CHALDECOTT. Harley-street, W., March 22nd, 1920.
A PERMANENT ARMY DENTAL CORPS. To the Editor of THE LANCET. SIR,—The Executive Council of the Federation of Medical and Allied Societies has, at the request of the British Dental Association, addressed a letter to the Medical Committee of the House of Commons, as well as to the medical Members of Parliament who are also members of the Federation, asking for support of the proposal of the Secretary of State for War, issued in explanation of the Army Estimates, that a permanent Army Dental Corps should be instituted. That this proposal may be rejected or curtailed in Committee on the grounds of economy is regarded as possible by the British Dental Association. The formation of such a corps was the subject of a scheme submitted by the British Dental Association at the request of the War Office in August, 1919, and it is felt that the interests of national health are concerned in ensuring that the recommendations of the Secretary of State for war, which constitute the minimum on which an effective dental service can be established, are given effect to. I
am.
Sir.
vours
fa.ithfnllv.
N. HOWARD MUMMERY, General Secretary. The Federation of Medical and Allied Societies, 5, were-street, Cavendish-square, London, W. 1, March 20th, 1920.
PARAPHRENIA. To the Editor
of THE LANCET.
from me to put a spoke in the wheel of progress ; but I would like to suggest that the term " chronic hallucinatory psychosis," introduced by Dr. R. H. Steen, and mentioned in your issue of last week, should be forthwith expunged : (a) because the term is applicable to many varieties of mental disease and is therefore liable to create confusion; and (b) because the disorder to which Dr. Steen refers has already received the name "paraphrenia." Following Kraepelin, I have described the malady under this designation in thCjIast edition of "Mind and its Disorders." As Dr.
SIR,—Far be it
Steen’s "acute hallucinatory psychosis"includes also some cases of melancholia (sic) and some of dementia praecox, the term stands self-condemned. My chief reason for this letter, however, is that Dr. Steen and some other speakers -at the discussion of ’
736 his paper recommended psychoanalysis as a mode of treatment for this malady. Having had some psychoanalytic experience of paraphreniacs, I wish to utter a warning that the resistances, which are already very strong in these patients, become increased on psycho-
The observations upon which this conclusion is based of the following type: A man suffering from diabetes mellitus, who excretes diacetic acid and &bgr;-oxybutyric acid along with a considerable quantity of sugar whilst on a diet extremely poor in carbohydrates, but rich in
analysis, that the ultimate result is unfavourable, and,
protein
therefore, that this mode of treatment is not to be recommended
or
attempted for such patients. Sir, yours faithfully,
I am,
W. H. B. STODDART. Cavendish-square, W., March 23rd, 1920.
THE CULTIVATION OF THE MENINGOCOCCUS. To the Editor
of THE
LANCET.
SIR,-Dr. H. Stanley Banks’s article in THE LANCET of March 13th on the Serum Treatment of Cerebrospinal Fever is of considerable interest. The cultivation of the meningococcus is, however, not always such a simple process as Dr. Banks suggests. " Coagulated blood serum" is, of course, a very suitable culturemedium, but in many instances gives no growth until incubated for 48 hours, and occasionally fails altogether even when the usual precautions, as mentioned by Dr. Banks, are taken. Hence it is a frequent occurrence that one is unable to report on the type of organism for two-three days after first seeing the patient. Obviously this is a serious drawback if the clinician ivishes to administer the homologous serum at once. My experience ?’6 agglutination is that the macroscopic is the most reliable, and that Gordon’s type sera are useless for the microscopic method. Theoretically, one should administer the homologous serum in any given case, but in practice I am not at all satisfied that it is a matter of great moment. I have examined many of the Lister sera for agglutinins to Gordon’s four types of meningococci, and have found that each type serum agglutinates each type of coccus up to a varying titrei.e., type 1 serum agglutinates not only type 1 coccus but also types 2, 3, and 4-similarly with type 2 serum, and so on. Type 4 coccus is extremely rare, so I always administer a mixed serum of type 1 and type 2. As type 3 coccus is so closely related to type 1 coccus, this Before mixed serum does well in type 3 infections. using this mixed serum one naturally must demonstrate to oneself that agglutinins for all three types are I am, Sir, yours faithfully, present. WILLIAM A. MUIR. Wallasey, March 17th, 1920.
ANÆSTHETICS AND DIABETES MELLITUS. To the Editor
are
and fat, may be found to lose his glycosuria and all evidence of acidosis on a diet, say, of 50 g. carbohydrate, 60 g. protein, 180 g. fat. This diet possesses sufficient energy to allow the individual to maintain his weight and do as much work as is necessary to earn a living by manual labour. This man has an accident An anæsthetic is administered and breaks his arm. to permit the arm being placed in the best position. After the an2esthetic sugar is found in the urine, and persists. Upon reinvestigating the maximum diet which will control glycosuria it is found that it has fallen to 20 g. carbohydrate, 60 g. protein, and 100 g. fat. Often the deterioration in the metabolism is much greater than this. The patient can no longer remain on a diet which allows his urine to be free from sugar and permits him to retain his weight and live a useful life. He is, therefore. forced to disregard his disease, eat more or less what he likes, and he develops coma at a comparatively early date. The unnecessary anaesthetic may have shortened his life by years. I quite realise that the presence or absence of sugar in the urine is not the best method of determining the optimum diet, but one which permits the majority of medical men making an attempt to do their best for the patient. In my opinion at the present day students should be taught that only operations that are absolutely essential should be performed upon diabetics ; that spinal anaesthesia and local anaesthesia, should be adopted when possible ; that nitrous oxide with oxygen is less likely to damage the patient than ether, and ether is less likely to do harm than chloroform. I am. Sir, yours faithfully, O. LEYTON. Portland-place, W., Nlarch 19th, 1920.
AFTER-EFFECTS OF MALARIA. 1.0 the Editor
of
THE LANCET.
SIR,-I have been very much struck during the last 18 months while examining soldiers on their discharge, and after their discharge, when claiming for pensions, by the abnormal number of cases of thickened arteries occurring in men between the ages of 20 and 28, who have suffered from malaria during some period of their service. Many of these cases apparently have only been of mild type, some have been undergoing quinine treatment for prolonged periods, others have not. I should be very glad to hear if this experience has been shared by other members of medical boards
of THE LANCET. SIR,—As a student I was taught that there was considerable risk in administering chloroform to patients suffering from diabetes mellitus. Fatal coma developed especially. I say that an examination of urine in these cases frequently within a day or two of the anaesthesia. This has may been a routine, and the condition of arteries appawas the result of and correct as far teaching experience rently exists in subjects which show no signs of, and in as it went, but since that time much has been added to whose history there is no evidence of, albuminuria. our knowledge of diabetes mellitus. We have known I am, Sir, yours faithfully, for some time that when suitable precautions are taken A. HURRELL STYLE, M.D. the risk of post-operative coma is comparatively small. Ministry of Pensions, Headquarters, Suffolk Area, We know, too-but perhaps it is not known to all, hence Church House, Bolton-lane, Ipswich, March 17th, 1920.
object of this letter-that the administration of any general anaesthetic, such as chloroform, ether, and THE GENESIS OF TWINS. nitrous oxide with oxygen, may leadto a comparatively 1’o the Editor of THE LANCET. into of of mellitus one diabetes developing slight case great severity. SIR,—In a recent number of Genet-ics’-Ihave presented It is only during the last five years that it has been statistical evidence which shows, I believe conclusively, possible to determine the gravity of any case of diabetes that it is far more probable that twins form a homomellitus, because the mere percentage of sugar in the geneous group of uniform origin than that they are of urine or the total quantity of dextrose excreted daily is two distinct types-"fraternal and " identical." Dr. no gauge to the extent of the alteration in the Thorndike’s data are, I believe, the only extensive body metabolism. Evidence seems to be accumulating that of measurements of twins, and from his data it appears diabetes mellitus is due to a change in the interacinary that (1) the variation in resemblance agrees closely cells in the pancreas ; that the severity of the disease with the variations due to sampling on the hypothesis depends upon the number of cells destroyed; that the of uniform origin, and is materially less than it would condition which has destroyed some cells has diminished be for dual origin ; (2) twins most alike in any one trait the vitality of others, and these may be killed by various are not more alike than other twins in other traits. toxins brought to them in the blood, amongst them In view of these facts the genesis of twins becomes a the
"
chloroform, ether, and nitrous oxide, and in all probability those elaborated by micro-organismssuch as cause scarlet fever, pneumonia, measles, influenza, &c.
new
problem,
and I have ventured to
put forward the
1 Princeton University Press, September, 1919.
are already in being organised. 7. The Central Committee has published in 1918 a special report on " Improvement of the Conditions of Childbirth in India " and in 1919 a report on " Venereal Diseases among
ment
of venereal diseases.
working order, the third is
agree with him. Certain it is that the matter cannot be settled by an invocation to Dr. Wharton Hood. I am old enough to remember that during his lifetime Dr. Wharton Hood was looked upon as hardly respectable. He wrote a large book in two volumes, a book almost forgotten. I should be surprised to hear that its precepts ever became a recognised basis of practice. I am, Sir, yours faithfully,
now
Women in India." This last contained confidential information, and was therefore circulated privately only. It must be remembered that the Central Committee has only had a subsidy of 10.000 a year for the Women’s Medical Service, and that owing to the demand for medical women in the war it has had extreme difficulty in keeping the service,up to strength. I am, Sir, yours faithfully,
-
1’0
M. I. BALFOUR, M.B., C.M.,
* ** Dr. Balfour has misread the title of our article, which dealt generally with the medical service of in India. With regard to our use of Dr. Wickham’s report, in the main report, which Dr. Balfour signs, it is stated: "The Central Committee from the many inspection reports in its own office can fully endorse the remarks made by Dr. Wickham and Dr. Scott, which apply to practically every part of India.’’ Our criticisms were directed, not against the Women’s Medical Service of India, or the work of the Lady Dufferin Fund, but against the difficulties under which they are placed. And it was our appreciation of these difficulties that prompted the plea for a State Service of women with conditions of local prestige, pay, and leave more nearly approaching those of the Indian Medical Service. Should such a change come about we have no doubt that the Government of India would avail itself of the extensive organisation of the Lady Dufferin Fund.-ED. L. women
I
MYALGIC PAINS AND MANIPULATION. To the Editor of THE LANCET. SIR.-With regard to Mr. R. C. Elmslie’s letter on this subject in your issue of to-day’s date, I am only too conscious of the assistance given to me by Mr. Elmslie himself, and other orthopaedic surgeons in the treatment of cases, to be in anyway unmindful of my obligations towards them-their special skill and ability are not questioned. The point is whether there is anything to be learned outside the ranks of the profession. Unless I am mistaken, an offer was made to demonstrate cases before a committee of surgeons; had this offer been accepted the whole matter would have been settled.-I am Sir, yours faithfully, W. H. CLAYTON-GREENE. Vimpote-street, BV., March 20th, 1920.
I
THE LANCET.
under this heading has wandered wide since its opening. Mr. E. C. Elmslie, in your issue of March 20th, endeavours to show the fallacy of the " myth " that a bone-setter possesses some mechanical skill denied to the regular surgeon, or, at any rate, to the regular orthopaedic surgeon. But with all respect I submit that a fallacy cannot be Mr. demonstrated by begging the whole question. Elmslie first gives the simple rules which govern the practice of the bone-setter. They are only two : first, restore mobility; second, restore the muscular power. Then he says : "Patients with derangement of the knee- , joint should only be submitted to operation when continued locking of the joint takes place in spite of the fact that mobility is full and the muscles strong." I I entirely misconceive the issues, unless I am right in believing that cases of this kind are precisely the cases that bone-setters profess to cure, and further, I, and many more of my profession, believe that we have personal knowledge of cases within this category which bone-setters actually have cured. Yet Mr. Elmslie says
I
operation only. Mr. Haldin Davis thinks that it is consonant with the dignity of the Royal College of Surgeons to appoint a committee of investigation to see if the case is as extremely simple as Mr. Elmslie suggests. I entirely
in your issue
March 20th, with which I entirely agree, will serve a I of useful purpose if it leads to some understanding as to
Delhi, Dec. 24th, 1919.
of SIR,-The correspondence
ANÆSTHETISTS’ FEES. the Editor of THE LANCET.
SIR,—Mr. H. Bellamy Gardner’s letter
Joint Secretary, Countess of Dufferin’s Fund.
To the Editoq,
C. G. HAVELL.
Felixstowe, March 22nd, 1920.
what fees special anaesthetists should now be entitled to charge. If it is admitted that their pre-war scale of fees was not excessive, it is obvious that the same rate of payment must be totally inadequate now, in view of the enormous increase in the cost of living. The practice of anaesthetics as a specialty has an appreciable influence upon surgical results, and it is in the public interest that the fees of a whole-time anoesthetist should be sufficiently generous for him to earn a good living. Unless it is recognised that this is impossible on the pre-war scale, specialism in anaesthesia will gradually be starved out of existence. In most districts general practitioners have met and agreed to raise their fees in some definite ratio. Why should anaesthetists not do likewise ? I am, Sir, yours faithfully, J. HENRY CHALDECOTT. Harley-street, W., March 22nd, 1920.
A PERMANENT ARMY DENTAL CORPS. To the Editor of THE LANCET. SIR,—The Executive Council of the Federation of Medical and Allied Societies has, at the request of the British Dental Association, addressed a letter to the Medical Committee of the House of Commons, as well as to the medical Members of Parliament who are also members of the Federation, asking for support of the proposal of the Secretary of State for War, issued in explanation of the Army Estimates, that a permanent Army Dental Corps should be instituted. That this proposal may be rejected or curtailed in Committee on the grounds of economy is regarded as possible by the British Dental Association. The formation of such a corps was the subject of a scheme submitted by the British Dental Association at the request of the War Office in August, 1919, and it is felt that the interests of national health are concerned in ensuring that the recommendations of the Secretary of State for war, which constitute the minimum on which an effective dental service can be established, are given effect to. I
am.
Sir.
vours
fa.ithfnllv.
N. HOWARD MUMMERY, General Secretary. The Federation of Medical and Allied Societies, 5, were-street, Cavendish-square, London, W. 1, March 20th, 1920.
PARAPHRENIA. To the Editor
of THE LANCET.
from me to put a spoke in the wheel of progress ; but I would like to suggest that the term " chronic hallucinatory psychosis," introduced by Dr. R. H. Steen, and mentioned in your issue of last week, should be forthwith expunged : (a) because the term is applicable to many varieties of mental disease and is therefore liable to create confusion; and (b) because the disorder to which Dr. Steen refers has already received the name "paraphrenia." Following Kraepelin, I have described the malady under this designation in thCjIast edition of "Mind and its Disorders." As Dr.
SIR,—Far be it
Steen’s "acute hallucinatory psychosis"includes also some cases of melancholia (sic) and some of dementia praecox, the term stands self-condemned. My chief reason for this letter, however, is that Dr. Steen and some other speakers -at the discussion of ’
736 his paper recommended psychoanalysis as a mode of treatment for this malady. Having had some psychoanalytic experience of paraphreniacs, I wish to utter a warning that the resistances, which are already very strong in these patients, become increased on psycho-
The observations upon which this conclusion is based of the following type: A man suffering from diabetes mellitus, who excretes diacetic acid and &bgr;-oxybutyric acid along with a considerable quantity of sugar whilst on a diet extremely poor in carbohydrates, but rich in
analysis, that the ultimate result is unfavourable, and,
protein
therefore, that this mode of treatment is not to be recommended
or
attempted for such patients. Sir, yours faithfully,
I am,
W. H. B. STODDART. Cavendish-square, W., March 23rd, 1920.
THE CULTIVATION OF THE MENINGOCOCCUS. To the Editor
of THE
LANCET.
SIR,-Dr. H. Stanley Banks’s article in THE LANCET of March 13th on the Serum Treatment of Cerebrospinal Fever is of considerable interest. The cultivation of the meningococcus is, however, not always such a simple process as Dr. Banks suggests. " Coagulated blood serum" is, of course, a very suitable culturemedium, but in many instances gives no growth until incubated for 48 hours, and occasionally fails altogether even when the usual precautions, as mentioned by Dr. Banks, are taken. Hence it is a frequent occurrence that one is unable to report on the type of organism for two-three days after first seeing the patient. Obviously this is a serious drawback if the clinician ivishes to administer the homologous serum at once. My experience ?’6 agglutination is that the macroscopic is the most reliable, and that Gordon’s type sera are useless for the microscopic method. Theoretically, one should administer the homologous serum in any given case, but in practice I am not at all satisfied that it is a matter of great moment. I have examined many of the Lister sera for agglutinins to Gordon’s four types of meningococci, and have found that each type serum agglutinates each type of coccus up to a varying titrei.e., type 1 serum agglutinates not only type 1 coccus but also types 2, 3, and 4-similarly with type 2 serum, and so on. Type 4 coccus is extremely rare, so I always administer a mixed serum of type 1 and type 2. As type 3 coccus is so closely related to type 1 coccus, this Before mixed serum does well in type 3 infections. using this mixed serum one naturally must demonstrate to oneself that agglutinins for all three types are I am, Sir, yours faithfully, present. WILLIAM A. MUIR. Wallasey, March 17th, 1920.
ANÆSTHETICS AND DIABETES MELLITUS. To the Editor
are
and fat, may be found to lose his glycosuria and all evidence of acidosis on a diet, say, of 50 g. carbohydrate, 60 g. protein, 180 g. fat. This diet possesses sufficient energy to allow the individual to maintain his weight and do as much work as is necessary to earn a living by manual labour. This man has an accident An anæsthetic is administered and breaks his arm. to permit the arm being placed in the best position. After the an2esthetic sugar is found in the urine, and persists. Upon reinvestigating the maximum diet which will control glycosuria it is found that it has fallen to 20 g. carbohydrate, 60 g. protein, and 100 g. fat. Often the deterioration in the metabolism is much greater than this. The patient can no longer remain on a diet which allows his urine to be free from sugar and permits him to retain his weight and live a useful life. He is, therefore. forced to disregard his disease, eat more or less what he likes, and he develops coma at a comparatively early date. The unnecessary anaesthetic may have shortened his life by years. I quite realise that the presence or absence of sugar in the urine is not the best method of determining the optimum diet, but one which permits the majority of medical men making an attempt to do their best for the patient. In my opinion at the present day students should be taught that only operations that are absolutely essential should be performed upon diabetics ; that spinal anaesthesia and local anaesthesia, should be adopted when possible ; that nitrous oxide with oxygen is less likely to damage the patient than ether, and ether is less likely to do harm than chloroform. I am. Sir, yours faithfully, O. LEYTON. Portland-place, W., Nlarch 19th, 1920.
AFTER-EFFECTS OF MALARIA. 1.0 the Editor
of
THE LANCET.
SIR,-I have been very much struck during the last 18 months while examining soldiers on their discharge, and after their discharge, when claiming for pensions, by the abnormal number of cases of thickened arteries occurring in men between the ages of 20 and 28, who have suffered from malaria during some period of their service. Many of these cases apparently have only been of mild type, some have been undergoing quinine treatment for prolonged periods, others have not. I should be very glad to hear if this experience has been shared by other members of medical boards
of THE LANCET. SIR,—As a student I was taught that there was considerable risk in administering chloroform to patients suffering from diabetes mellitus. Fatal coma developed especially. I say that an examination of urine in these cases frequently within a day or two of the anaesthesia. This has may been a routine, and the condition of arteries appawas the result of and correct as far teaching experience rently exists in subjects which show no signs of, and in as it went, but since that time much has been added to whose history there is no evidence of, albuminuria. our knowledge of diabetes mellitus. We have known I am, Sir, yours faithfully, for some time that when suitable precautions are taken A. HURRELL STYLE, M.D. the risk of post-operative coma is comparatively small. Ministry of Pensions, Headquarters, Suffolk Area, We know, too-but perhaps it is not known to all, hence Church House, Bolton-lane, Ipswich, March 17th, 1920.
object of this letter-that the administration of any general anaesthetic, such as chloroform, ether, and THE GENESIS OF TWINS. nitrous oxide with oxygen, may leadto a comparatively 1’o the Editor of THE LANCET. into of of mellitus one diabetes developing slight case great severity. SIR,—In a recent number of Genet-ics’-Ihave presented It is only during the last five years that it has been statistical evidence which shows, I believe conclusively, possible to determine the gravity of any case of diabetes that it is far more probable that twins form a homomellitus, because the mere percentage of sugar in the geneous group of uniform origin than that they are of urine or the total quantity of dextrose excreted daily is two distinct types-"fraternal and " identical." Dr. no gauge to the extent of the alteration in the Thorndike’s data are, I believe, the only extensive body metabolism. Evidence seems to be accumulating that of measurements of twins, and from his data it appears diabetes mellitus is due to a change in the interacinary that (1) the variation in resemblance agrees closely cells in the pancreas ; that the severity of the disease with the variations due to sampling on the hypothesis depends upon the number of cells destroyed; that the of uniform origin, and is materially less than it would condition which has destroyed some cells has diminished be for dual origin ; (2) twins most alike in any one trait the vitality of others, and these may be killed by various are not more alike than other twins in other traits. toxins brought to them in the blood, amongst them In view of these facts the genesis of twins becomes a the
"
chloroform, ether, and nitrous oxide, and in all probability those elaborated by micro-organismssuch as cause scarlet fever, pneumonia, measles, influenza, &c.
new
problem,
and I have ventured to
put forward the
1 Princeton University Press, September, 1919.