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It is thus the lawyers and not the doctors who inthe present instance are the primary advocates of

change. This fact does not appear to have been

kept adequately in view in the proposals put forwardin the two medical memoranda ; and it is probablethat legal critics may complain that neither of thesedocuments offers any constructive suggestions, exceptin regard to the mode of presenting expert evidence,which go to meet the admitted difficulty of justice indealing with offenders on the borderline between sanityand insanity. The absence in this connexion fromboth memoranda of any reference to the principle ofdiminished responsibility, which is being adopted asa partial solution of this difficulty in other countries,weakens the statement of the medical position. Onthe other hand, both subcommittees have addressedthemselves to the task of amending the legal test ofresponsibility ; the memorandum of the BritishMedical Association proposes to add a clause recog-nising morbid incapacity of control as a ground of

irresponsibility, and also suggests a modification ofthe wording of the test in regard to the power of

knowing and appreciating the character of thecriminal act. It is always rather risky for medicalmen to involve themselves in the subtleties of legalphraseology, and it is not unlikely that some memberof the Lord Chancellor’s Committee may be inclinedto make caustic comment on the proposal that a

murderer should be held irresponsible on account ofmental disability, if such disability, though not

interfering with his knowledge of the nature and

quality of his act, prevented him from " appreciatingthe circumstances in which it is done "-such a circum-stance, e.g., as the presence of an unobserved witness.The Medico-Psychological subcommittee seem to havebeen better advised in deprecating any analytical testof legal insanity, and in proposing that, instead of theM’Naughton Rules, the judge should put the issueto the jury in the form of three questions : (a) Didthe prisoner commit the act alleged ? ’? (b) If he did,was he at the time insane ? (c) If he was insane, hasit nevertheless been proved to the satisfaction of thejury that his crime was unrelated to his mentaldisorder ? A This way of formulating the issue wouldallow the expert witness to give his evidence in hisown language without having to obscure and distortit by translation into terms of legal technicalityalien to his training and manner of thought, and itwould thus make his statement of facts and con-clusions far more accessible to the common sense ofthe jury. At the same time, without introducing anygreater laxity than already exists in practice underthe present system, it would remove from the

English law the reproach of maintaining an obsolete,unscientific, and ineffectual formula.A matter of equal, if not greater importance than

the terms of the legal test of insanity, is the mode inwhich expert evidence is put before the court in casesinvolving this issue. On this point there is a markeddivergence of opinion between the two medical-subcommittees ; the memorandum of the BritishMedical Association insists rightly and forcibly on thedefects of the existing system by which expertevidence of insanity is given by ex-parte witnesseson either side, to the confusion of judge and jury,and, in the case of persons without means, possiblyto the prejudice of justice ; it advocates insteadthe provision of machinery for the independent andimpartial mental examination of accused persons bya member or members of a panel of psychiatricphysicians of recognised standing, whose reportshould be furnished to the prosecution and to thedefence, and should be supported by personal evidence

in court. For some undisclosed reason the idea of

impartial expert witnesses does not seem to havecommended itself to the Medico-Psychological sub-committee. who devote merely a few lines to it in theirmemorandum, rejecting any proposal of a system ofmedical assessors, but admitting that " it might bepossible " to appoint a panel of accredited experts,to be employed at the discretion of the court, butwithout interference with the existing system of

ex-parte evidence. Both subcommittees are in agree-ment in opposing any alteration of the section ofthe Criminal Lunatics Act which empowers theHome Secretary to institute a statutory inquiry intothe mental condition of prisoners under sentence ofdeath. As a safeguard against possible miscarriagesof justice some procedure of this sort is obviouslyessential, and if the enactment establishing it wererepealed, popular clamour would insist on its restora-tion on the occurrence of the first case of doubt as tothe sanitv of a condemned murderer.The memoranda also make a number of recom-

mendations, many of them rather debatable, on

matters of subsidiary importance, such as the rightof appeal from the verdict of "Guilty, but insane,"and the position of those unfit to plead. Thesememoranda represent the outcome of much pains-taking labour, and they deal with questions in whichthe medical profession has a serious and responsibleinterest. On that account the conclusions will besympathetically as well as carefully scrutinised, andany criticisms which may be passed upon them will,no doubt, be tempered by a due recognition of theextremely difficult and complex character of thequestions which the subcommittees had to consider.

TUMOURS OF THE BLADDER.URINARY disturbances of any kind, apart from what

innately bad qualities they possess, bring in their trailan immense amount of physical and mental suffering.If they are irremediable, as so often happens whenmalignant disease has been allowed to progress toofar, the plight of the victims is truly pitiable. New

growths of the bladder must be included amongst thevery grave urinary diseases. They possess certaincharacters which are seen scarcelv anywhere else in thebody. The papillomata, which are quite benign andlocal growths, show an extraordinary capacity for

grafting portions of their substance on other partsof the bladder mucosa. They exhibit almost theinfective characteristics of warts of the skin, in themanner in which they will give rise to satellite lesions,but, unlike the cutaneous papillomata, they unfortu-nately show no propensity to sudden and inexplicabledisappearance. Another notable feature of bladdertumours is the fact that, to the naked eye, a malignantgrowth may be indistinguishable from a simplepapilloma, and even under the microscope differen-tiation becomes possible only when the growinginfiltrating margin at the base comes under view. Afortunate circumstance is that distant secondarygrowths occur late, or perhaps local spread gives riseto early symptoms and so calls attention to the

presence of some bladder lesion. But though haemat-uria, the cardinal symptom of bladder tumours,occurs early, it is very often only an evanescentmanifestation and so is apt to be disregarded.

In his lecture delivered at the Mayo Clinic,and printed in three recent issues of THE LANCET,Mr. FRANK IiiDn reiterates his teaching of years, thathæmaturia necessitates cystoscopy. Even in thesedays the practitioner does not always follow thiscourse, for lie knows very well that many cases of

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hæmatuna of renal origin, without demonstrablelesions, occur once, never to reappear. Neverthelessthis is a policy dangerous to pursue, for delay mayrender radical treatment dit’ficult, fraught with greatrisk, or altogether impossible. Mr. KiDD’s views onthe treatment of vesical tumours based on a personalexperience of 162 cases claim great respect. Few

surgeons have dealt with so many patients of whomthey have accurate notes of the early and remoteafter-histories. That 90 per cent. of simple papillo-mata may be cured by Beer’s fulguration method is animmense advance on the old intravesical excisions,where secondary implantation almost invariablyoccurred. Mr. KIDD favours the destruction of

papillomata if possible at one sitting under generalanaesthesia, in contrast with the multiple cauterisationswhich many urologists carry out. What is notable also, is the possibility of curing completely an Iearly malignant growth by diathermy through the

cystoscope. Other surgeons of less experience can corroborate this statement, although microscopicdemonstration of the nature of the tumour is

impossible, as it is destroyed. They would be certainto confirm the observation that some small malignantpapillomata are very resistant to diathermy. Theresults Mr. KiDD has obtained by operative removalof malignant tumours, using a modified Squier’stechnique, are remarkable : 11 out of 28 patients areknown to be alive and well from one to 11 yearsafter operation. This result is not possible ofachievement by the older technique of excision aftercystotomy. It renders the outlook for the unfortunatesufferer from a malignant tumour of the bladder farless grave than it is commonly believed to be.

RECENT WORK ON BLOOD-SUGAR.- CARBOHYDRATES and proteins take precedence in

biological chemistry over other compounds, inasmuch_ as they are essential to life and growth, and an

additional stimulus was added to the study of carbo-hydrate metabolism when WILLIS showed thatdiabetes mellitus was associated with glycosuria.The landmarks in the growth of this knowledgeare too well known to recapitulate here. Recently,however, experimental data have been publishedwhich substantially modify the existing views.First and foremost, under the inspiration of Prof.J. J. R. MACLEOD, the Toronto School have been ableto produce an active pancreatic preparation, the

injection of which reduces the blood-sugar and

produces an intermission in the glycosuria of diabetics.Insulin is in fact the first striking success in a seriesof investigations, begun by MINEOWSKI when he

produced diabetes by depancreatising animals, andhitherto almost fruitless. The comparative scarcityof ox pancreas has naturally led laboratory workersinterested in insulin to look around for a more

abundant raw material. What more natural thanthat they should turn to yeast, whose enzyme hasbeen known for years to break up glucose into carbondioxide and alcohol, a process which probably occursalso in the body. Long before the announcementof insulin physicians saw in yeast the cure of diabetes ;but apart from rendering patients extremely uncom-fortable with eructations, no therapeutic effectfollowed its administration. Early this year1 someexperimental work was published from the Bio-chemical Laboratory at Cambridge on solid extractsof yeast. In this Messrs. L. B. WINTER and W.SMITH put forward a new theory of the causation of

1 Brit. Med. Jour., Jan. 6th, 1923.

diabetes. They state that the sugar present innormal blood is an unstable form, which they call

-y-gliicose. In diabetic blood they find onlystable forms of glucose, and from this they concludethat the pancreatic internal secretion-and probablyinsulin-act by converting the stable into the unstableglucose, thus rendering it suitable for metabolism.

They also suggest that yeast may act in this way,for injections into rabbits lowered the blood-sugarand put rabbits into convulsions. These experi-ments raised the hopes of clinicians, who could seelarge quantities of this

"

yeast insulin " being availablefor clinical trial in the near future. The investigatorsthemselves were guarded in their statements, andmuch work remains to be done before definite con-clusions can be reached. Substances, such as peptoneand certain proteins, all of which are contained in

yeast, are known to lower the blood-sugar on injection.. With regard to the theory of stable blood-sugarin diabetes it is true that glucose, containing as itdoes asymmetric carbon atoms, can exist in manyisomeric forms. TANRET, who discovered twodistinct forms possessing different rotatory powers,showed that when a-glucose was dissolved in water,its rotatory power fell to a constant figure, and that

&bgr;glucose, when treated similarly, gave a rising rota-tory power. He also found a third substance, which hecalled ’y-glucose, of constant rotatory power. But asknowledge grew it turned out that in solution a- and

&bgr;-glucose changed into each other, until a definitepoint of equilibrium was reached, and that -y-glucosewas nothing more nor less than a mixture of thesetwo substances in equilibrium. This fact, now

admitted by TANRET himself, is difficult to reconcilewith the new theory of diabetes. The constant

change in solution of carbohydrates is a beautiful

example of the adaptation of organic compounds tothe use of the living organism. Enzymes are extra-ordinarily specific with regard to their action onthese carbohydrate isomers. One enzyme will onlyact on /3-glucose, and, but for this process of muta-rotation, no carbohydrate metabolism would bepossible. If only the a form is supplied, this goesinto solution and at once dissociates into /3-glucose,until a definite equilibrium point is reached betweenthe two bodies. The enzymes then remove someof the metabolisable compound, with the resultthat the equilibrium is upset ; more of the a formdissociates to the 13 compound, which in turn isremoved. Thus the process goes on until all hasbeen metabolised. No enzyme is necessary to converta- into /3-glucose, for nature has already provideda spontaneous means in this process of mutarotation.Had Prof. LOWRY, speaking at the recent Pasteur

evening of the Royal Society of Medicine, overlookedthis phenomenon when he condemned ALICE to a

glycosuric death when she entered the realm beyondthe looking-glass ’? For he pointed out that her

enzymes being reversed could only act on lævo-

compounds. But even if the looking-glass did notalso reverse the carbohydrate molecules-and whyshould it not ’?—mutarotation must have savedALICE from becoming diabetic.On p. 715 of our present issue Dr. H. F. MOOREgives a useful conspectus of the views at presentcurrent as to the physiological effects which insulinhas on the body. It has now been placed beyonddoubt that insulin reduces the blood-sugar ; unless,indeed, its administration is controlled the reduction

may go so far as to endanger the well-being and eventhe life of the animal. In the diabetic, coincidentwith the reduction of the hyperglycaemia, there isa reduction of the formation of acetone and other