301

shape, appearance, rate of growth, finger-prints, (

differential blood counts, illnesses, scholastic records, i

mental characteristics. muscular power, and all imeasurable qualities were compared, and a remarkabledegree of resemblance was revealed. The similarityai twins may lead in real life to many embarrassing,1fI.i even sensational situations, while since thedays of Terence it has furnished material for theplots of dramatists and story-tellers ; it is a subject,therefore, which always leads to general discussion. ’This has occurred in respect of Dr. Crowden’s twins,and our reference to the resemblance of their finger-prints has been translated by the press into a state-ment of absolute identity. Dactylography is sucha powerful weapon in legal hands, that the Commis-sioner of Police of the metropolis has received inquiriesfrom finger-print experts all over the world, callingattention to the statement in various newspapers.that the finger-prints of these twins had been foundto be identical, and asking for particulars. Asa result, the Commissioner has replied to thesemquiries by pointing out that the finger-prints ofthese twins are not identical, and, further, thatDr. Crowden had never made any assertion to that effect, contenting himself (as in our columns) withstating that they were " very much alike." Repro-ductions of the impressions have been obtained byNew Scotland Yard and examined, with the resultthat. the ridge characteristic data disclosed werefnund to be absolutely dissimilar. The estimationof finger-prints is a very exact procedure, and it

’is clear that a superficial resemblance may concealfundamental variations.

DIURNAL TIDES OF LEUCOCYTES.

IN his Ars Anatomica of 1714 the ingenious (Dr. Salmon engages in a discussion of the rate of the tcirculation in man. Perceiving that he can obtain his answer if he knows the blood volume, cardiac (output, and pulse-rate, he calculates that a man ]has (in modern measures) about 11 litres of blood, land that the left ventricle expels about I 3 c. em. at each systole, and observes with his niinute watchthat the heart beats about 60 times a minute. ]

Whence he deduces that all the blood in the body goes round once in about four hours. Horrified atsuch a violent and extravagant motion, he concludes ;by satisfying himself that it is .much more agreeableboth to nature and reason to believe that the bloodebbs and flows in harmony with the sea, and circulatestwice every 24 hours. We know now that it goesround once a minute, or rather faster, when the bodyis at rest, but this naive confidence in the harmonyof man with all nature is recalled by an interestingstudy of the fluctuations in the number of leucocytesin the blood by Dr. A. F. Bernard Shaw, of Newcastle,which appears in the current number of the Jozcrnalof Pathology and Bacteriology. Dr. Shaw finds thatthe total leucocyte count may vary by 1000 or 2000at short intervals-15 minutes or even less-andthat these small oscillations are imposed on two maintidal waves, one reaching its maximum in the after-noon, the other soon after midnight. These changesare due to fluctuations in the number of neutrophilecells, and the lymphocytes and other varieties arenot involved ; he also produces evidence that theleucocytes are uniformly distributed in the peripheraland central circulations. What is more surprising,however, is the discovery that the day and nighttides occur regardless of food, exercise, and sleep,which have no clear influence on them ; nor are thecurves of lencocytes synchronous with the dailycurve of body temperature. It is shown once morethat " digestion leucocytosis

" is imaginary, andwe hope that myth is now exploded for good. Butthe leucocyte tides are left in a mysterious state,and it still seems likely that the apparent independ-ence of food and sleep would disappear with alonger trial of an inverted mode of life. It takestime for cells to multiply and grow, and rhythmicalhabits impressed on tissues by immemorial rhythms

of personal and ancestral conformity with the clockmay well last through the trivial irregularitiesintroduced by experiiiient.

THE WEBER COLLECTION.

THE first two volumes of the great collection of Greekcoins formed by the late Sir Hermann Weber, M.D.,were reviewed in THE LANCET on their appearance.1The first part of the text of Mr. Forrer’s third volumezhas now appeared. together with a portfolio of plates toillustrate the whole volume. The coins dealt with inthis portion (Nos. 4744 to 6967) are those of the sea-board countries of Asia Minor from the Bosporus toLydia, and they are illustrated on Plates 172-247.We have already mentioned the fact that by meansof a special grant from the Treasury, many of the mostnoteworthy coins in the Collection have been acquiredfor the British Museum. This provision has beensupplemented by a grant from the National ArtCollections Fund, by the generosity of privateindividuals, and not least by the generous opportunitiesfor pre-emption offered by Messrs. Spink and Son.The extent to which the National Collection has beenenriched can nowhere be better illustrated than fromthis section of the catalogue. Among the mostbeautiful of ancient Greek coins are the rare goldstaters, dating from the early fourth century B.C.,of the celebrated Hellespontine city of Lampsacus.The Weber Collection contained no less than nineof these staters, of which two are unique, two knownonly by one other specimen of each, and a fifthknown only by two other specimens. All five coinsare now in the British Museum, including a remarkablecoin which has for type a Nike sacrificing a ram.

Farther along the coast of the Propontis was anotherof the big coin-producing cities of antiquity, thetown of Cyzicus, whose electrum staters took theplace of an international gold currency during thecenturies before Philip of Macedon opened thePangaean gold mines, and Alexander the Great afterhim sent the great stores of gold from his Easternconquests into currency. This electrum is a naturalalloy of gold and silver washed down by the greatrivers of Asia Minor, and it was in this metal that thepeoples of the Ionic seaboard first coined money,probably ca. 750 B.C. Many of the cities of this partof the world have primitive coins of electrum,and in some places the use of the metal persists,although silver may also have become available.The Cyzicene staters are much sought after by thecollector, and it is surprising to find as many as

41 in the Weber Collection. Many of these derivefrom famous collections of the last century, includingthose of Lord Ashburnham and Canon Greenwell.Other electrum coins here represented are those ofPhocaea, the small unidentified early coins of thecities of Ionia, the pretty one-sixth stater piecesof Lesbos, and two of the electrum staters which inrecent years Prof. P. Gardner has identified as thecoinage of the towns leagued together in the Ionianrevolt against Persia at the end of the sixth centuryB.C. A later example of a presumed federal or alliancecoinage is perhaps to be found in two examples atEphesus of the very rare coins issued about 390 B.C.by Ephesus, Rhodes, Cnidus, Iasus and Samos.These coins bear a common type, the infant Heraklesstrangling the two serpents, but if thereby an allianceis denoted no literary record of the event has sur-vived. Among other coins of outstanding interestare a unique tetradrachm of Smyrna of the fourthcentury B.C. well known from previous publications,a superb tetradrachm of Cnidus, two fine tetradrachmsof Cos, and a very fine and rare stater of Amastris.These coins are now all in the British Museum,the coin of Cnidus being a contribution from the

. National Arts Collection Fund. Many of the cities

1 THE LANCET, 1923, i., 199 ; and 1925, i., 665.2 The Weber Collection. Vol. iii., Part 1, Asia, Bosporus,

Colchis, Pontus, Paphlagonia, Bithynia, Mysia, Troas, Aeolis,Lesbos, Ionia, Caria, Lydia. By L. Forrer. London : Spinkand Son. 1926. Pp. 473. With portfolio of 136 plates. £4 4s.

302

where the coinage is less spectacular are well repre-sented, and there are many varieties, new or notwell-known, of the later imperial coinage of theGreek towns when under the rule of the RomanEmperors. It remains to add that Mr. Forrer hasperformed his pleasant task with the thoroughnessand care which marked the earlier volumes.

DIAPHRAGMATIC HERNIA.

HERNIA through the diaphragm was known as longago as the days of Ambroise Paré. At the autopsy onan officer who died in great pain eight months after abullet wound, Pare found a large distended loop ofthe colon in the thoracic cavity ; the hole by which ithad entered was, he tells us, too small to admit thelittle finger. For many decades, however, the conditionremained a mere curiosity of the dissecting-table.Now and again a writer would describe it, and suggestsuch remedies as bandaging and blistering. Bowditchand Pean, in 1865 and 1880 respectively, justifiedoperation as a last resort, but on the whole thecondition received little attention until the late war.when the daily occurrence of cases similar to Paré’sbrought it into prominence and enabled it to be studiedexhaustively. Moreover, the use of X-rays revealeda group of herniae that were congenital and nottraumatic at all, and a whole series that would neverhave been discovered, because of the absence of strangu-lation. Dr. Jean Quénu,1 in a recent summary of thesubject to which he contributes much first-handinformation, gives an idea of the frequency ofdiaphragmatic hernia when he states that there arenow over 1500 cases in the literature. He classifiesit as congenital and traumatic. The congenital formis due to a failure of the two parts of the diaphragmto meet properly, and so nearly always occurs postero-laterally. It is much more common on the left side,probably because the liver protects the right cupola,whereas the stomach exerts heavy pressure on theleft. Traumatic herniae, which are always left-sided,are generally the result of stabbing or shootingwounds. Often the hernia is not immediate but takesplace some time afterwards, when a blow or

violent effort forces the weak barrier of the healedscar. Nevertheless, Dr. Quenu holds that many so-called secondary herniae are really primary ones

which have been neglected. A congenital hernia,he finds, nearly always involves the stomach, thetransverse colon and the great omentum, and some-times takes in parts of the small intestine, cecum,liver, and pancreas. The organs are, as a rule, freefrom attachment to the thoracic cavity and are easy towithdraw, but sometimes, when an old traumatichernia has coincided with a more or less septichaemothorax, there are very intractable adhesions.The great omentum may form a false sac over theintruding mass. The true sac is very rare and is hardlyever seen except in " f oetal " herniæ—i.e., thosedeveloped later in the intra-uterine life than thecongenital or embryonic herniæ. It is easy to realisethat strangulation at the point of rupture may causevery severe lesions, such as perforation, with anescape of gastric or intestinal contents into thepleural cavity.

According to Dr. Quénu, the symptoms of a largehernia involving both stomach and colon are thoseof acute gastric, intestinal, or cardio-pulmonarydisturbances, always accentuated by meals. Signsof displacement are sometimes fairly obvious andsometimes elusive : they vary in different patients,and in the same patient from time to time, and alterwith changes of position or the presence of food inthe alimentary tract. Radiography often makesdiagnosis a simple matter, and the hernia can some-times not only be seen but be accurately measured ;some cases, however, simulate diverticulum of theœsophagus or an abnormally high cupola of thediaphragm. The former are generally exposed bywatching the way in which the pocket fills and empties,

1 Arch. Med.-Chir. de l’App. Resp., 1926, i., 356.

and by the presence of the shadow of a normalstomach underneath. The latter may offer somdifficulty, especiaily when the diaphragmatic conditionis of the kind described by J.-L. Petit in 1780 as" eventration," when the diaphragm undergoes

distension at one point and is pushed upwards intothe pleura in the shape of a deep, narrow dome. Whenthis has happened, the resulting photograph ispractically identical with one of a hernia. Dr. Quénurecounts various ways of making the diaphragm caeta clearer shadow and reveal its position, and correct-ness of diagnosis is important in that, whereas herniademands operation, eventration is generally betteleft alone.The treatment varies according to whether the

hernia is a traumatic or strangulated one requiringimmediate operation, or one which can be dealt withat a chosen time. Dr. Quénu describes as the typicaloperation one which begins with an exploratoryincision in an intercostal space, varying from thesixth to the tenth according to the site of the rupture.The aperture is prolonged through the abdominalwall to the middle line, opening all the soft parts andthe peritoneum. An incision is then made throughthe costal cartilage and the diaphragm to the siteof the hernia. Adhesions are freed and the ectopicorgans withdrawn. The orifice is obliterated and thediaphragm sewn up at different points as far asthe chondral attachments. In closing the thorax, theintrapleural air is exhausted with a syringe. Thepneumothorax produced by the operation has neverbeen Known Do nave iii-enects, ana tne mapnragmheals extremely well. If much of its substance hasto be removed, there are several ways of filling thegap. Different operators have used the stomach, apiece of omentum, the left lobe of the liver, a lung,or a graft of muscle from the abdominal wall. Dr.Quénu suggests that a free graft of aponeurosis mightbe the most satisfactory method, but it has not yetbeen tried. Operation for strangulated diaphragmatichernia is an emergency, and the condition is verygrave indeed, but the method described allows thepatient the most reasonable chance of recovery.

RENAL DWARFISM.

IT is mainly owing to Dr. H. Barber, who published*the first three cases of his remarkable series in 1913,that the rare condition known as renal dwarfism has -

been rescued from the limbo of " late rickets " andrecognised as a separate entity. Its importance lies -

in the invariably fatal results that follow operativetreatment of the deformities associated with it.The fundamental pathology consists of an extremedegree of chronic interstitial nephritis, unaccompaniedby oedema, and with little or no cardiovascaisthypertrophy. In the later stages calcification atthe epiphyses becomes very deficient and deformitycommonly follows. Great stunting of growth is afeature in all cases, and girls are affected rather,more often than boys. The renal symptoms appearinsidiously in early childhood with thirst andpolyuria and may pass unrecognised by the parents,but gradually attacks of drowsiness, headache, and -

vomiting supervene, and death in uraemia occurs onthe average about the twelfth year. Deformity ispresent in some 70 per cent. of cases and may comeon before the symptoms of renal disease are noticed. -

The type varies with the age of onset. Before the ageof nine it takes the form of slipping and displacementof the epiphysis on the diaphysis. The lesions are . -

painless. They affect mainly the knees and wrists,but frequently the ankles and shoulders as well, andcause great disability. Radiographically the appear- .:ance is striking and distinctive. After the age ofnine separation of epiphyses does not occur, and the

=

deformities cannot be distinguished from those ofso-called late rickets. Genu valgum is by far the mostcommon deformity in this type of case. The diagnosisis usually easy if the condition is borne in mind, aaa

1 Brit. Med. Jour., 1913, ii., 1204.