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oesophagus and the colon this is due to the

incompleteness of our knowledge of their nerve-supply ; but in the case of the limbs it is attribut-able to the conflicting evidence of physiologicalexperiment and surgical experience regarding therelative values of preganglionic and postganglionicsections. WHITE’S experiments seem to showthat removal of the ganglion cells renders thedenervated vessels over-sensitive to the actionof circulating adrenaline, and some clinicianshave seized upon these observations to explainwhy the results of lumbar ganglionectomy, whichis a preganglionic section for the foot, are on thewhole so’ much better than those of cervicothoracic

ganglionectomy, which is of course postganglionicfor the hand. TELFORD suggests dividing thethoracic trunk below the third ganglion in orderto achieve preganglionic section of the arm supply,and points out that this operation has the addedadvantage of avoiding the unwanted Horner’ssyndrome, which is inevitable after excision of thestellate ganglion. The late results of this opera-tion will be awaited with much interest.

In attempting to explain the recurrence of

symptoms after sympathectomy regeneration ofnerve tissue after a properly conducted operationmay be left out of account, and it is probable thatthe secret lies in the automatic activity which the

1 White, James C.: The Autonomic Nervous System, 1935, p. 92.

organs innervated by the sympathetic all seemto possess. The loss of sympathetic control maysometimes render them more susceptible to stimula-tion by adrenaline, but there is another factorwhich must not be forgotten. The analysis of theresults of sympathectomy prepared for the Associa-tion of Surgeons by PATERSON Ross shows thatthe success of these operations largely dependson the severity of the disease for which the opera-tion has been performed. This is especiallynoticeable in Raynaud’s disease, in thrombo-

angiitis obliterans, and in the cold blue legs of

poliomyelitis and erythrocyanosis, and it maybe generally accepted that sympathectomy is of

greatest value in the early stages of disease, whendenervation may help to rectify a disorder in thefunction of an organ which has not yet sufferedany considerable alteration in its structure.Recurrence of symptoms after operation is not

infrequently due to such structural changes, signsof which again manifest themselves after theearliest paralytic phenomena of denervation havepassed off. Judgment should not be passedupon the value of sympathectomy without givingcareful consideration to the nature of the diseasefor which it is practised. There is no doubt thatthe results are often disappointing, but this is thefault not of the operation but of the surgeon whohas failed to take sufficient care in selecting thecases suitable for sympathectomy.

ANNOTATIONS

THE RIGHT TO DIE

EARLY in December a meeting is to be held at thehouse of the Royal Society of Medicine to inauguratea public society, to be known as The VoluntaryEuthanasia (Easy Death) Legalisation Society, whichhas been formed under the presidency of Lord

Moynihan with Mr. C. J. Bond as chairman of theexecutive committee and Dr. Killick Millard as

hon. secretary. The society owes its origin to Dr.Millard, who three years ago devoted to this subjectthe whole of his presidential address to the Societyof Medical Officers of Health, submitting for theirconsideration the draft of a Parliamentary Bill tolegalise the painless killing, at their own wish, of

persons suffering from incurable, fatal, and painfuldisease. This draft Bill has since been revised byhigh legal authority without substantial modificationand is now ready to be introduced by Lord Moynihanin the House of Lords at some suitable time. Tomeet possible objections on religious grounds, a

statement that voluntary euthanasia as proposed bythis society is not contrary to the principles of

Christianity has been drawn up and signed by anumber of representative anglican and nonconformistministers. The proposal too is regarded as gainingsupport from what Sir (Saint) Thomas More wrotein " Utopia

" about euthanasia, although he did notactually use the word. Copies of the draft Bill,price 6d., can be obtained from Dr. Millard at TheGilroes, Leicester.

WHITE BILE

THE discovery of colourless contents in the gall-bladder or bile-ducts is unusual, and the surgeonmay find it hard to assess its significance. Wherethe gall-bladder is completely isolated the assumption

will be that its wall has absorbed the bile-pigments,and examination of the contents will show that thebile salts, too, have been absorbed. The fluid maybe clear or turbid, and the condition may be theoutcome of obstruction of the cystic duct either bytumour or by calculus. That a somewhat similarcondition may arise in the isolated bile-ducts wasdemonstrated by a case reported last year byMr. Norman Lake. This was one in which thelower ends of the common bile-duct and of the cysticduct were simultaneously blocked by new growth,and the result was enormous distension of the bile-ducts, to the calibre of the jejunum, their contentbeing as colourless as cerebro-spinal fluid. E. Melchior now points out that there is a distinction between thecase in which the liver and ducts are still excretingbile of normal colour-which is later decolorised-and that in which there is a failure, primary orsecondary, of the liver cells. Quite often this failureis due to back pressure through blockage of theducts, and drainage of the biliary system may restorethe normal liver function and relieve the associatedjaundice. In other cases the hepatic failure appearsto be primary, without biliary obstruction. Melchiorthinks, however, that there is no essential differencebetween the two classes of case, once the damage tothe liver cells has gone far enough. Most probably,he believes, infection plays a considerable part in thecausation, although he cites cases in which bacteriacould not be found. His advice is that when there isbiliary obstruction and the common bile-duct isfound to be distended with clear colourless, or

milky fluid, the prognosis should be guarded,especially if the obstruction is suspected to be of

1 THE LANCET, 1934, ii., 753.2 Presse méd., August 21st, 1935, p. 1316.

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long duration. After operation the reappearance ofpigment in the bile draining through the tube isof course a good sign, but final failure of the liveroccurred in some of his cases, with reappearance ofcolourless " bile." Sometimes the flow of fluidwas excessive, a condition which Melchior terms" hypercholorrhee " _ being established. Two litresor more of colourless fluid might drain in the day,and the patient suffer accordingly from the symptomsof rapid fluid loss, sometimes with widespreadhaemorrhages (visceral and subcutaneous) in addi-tion. The liver is apt to be tense, enlarged, and firm,and its surface is spotted with tiny white channelslooking somewhat like abscesses. These are thesmall hepatic ducts distended with the same whitefluid that appears in the main ducts.

THE FORENSIC CHEMIST

MINDFUL of the debt which legal medicine owesto chemistry, the Medico-Legal Society have electedMr. C. A. Mitchell, D.Sc., to be their president.In the address delivered to them on Oct. 24thhe was able to show how wide had been the applica-tion of chemistry in the courts during the last fiftyyears. In the trial of Palmer, the Rugeley murderer,in 1856 the chemical evidence of strychnine in thebody of Cook was discredited by the medical evidenceadduced for the defence. Nowadays the chemicalevidence is often more decisive than the clinical

findings, and many branches of evidence are nowexclusively within the province of the chemist.In questions concerning the adulteration of food anddrugs the public analyst has won an independentand highly specialised position, and there are nowmore non-medical than medical toxicologists availableto assist the police. Only the chemist has been ableto explode such medical fallacies as the belief that adrunkard may die from spontaneous combustion,or that a body buried in quicklime is destroyed.Chemical evidence, by showing that fire could startby the accidental mixing of such common drugs aspermanganate and glycerin, induced the Court of

Appeal to hold that the fires in Kingstown at thetime of the Jamaica earthquake in 1907 started as theresult of the earthquake and not before it. Thechemist is often called upon to identify the woodfrom which charcoal is made by examining its

microscopical structure ; to decipher writing on

burnt paper; or to decide whether material is damagedby salt or by fresh water. By identifying the duston the clothes of an Egyptian suspect with the fire-proof lining of a broken safe, a chemist of Cairobrought a burglar to justice, and a coiner was convictedon the evidence of a single particle of alloy found onhis file and identical with the metal in counterfeitcoins which he was charged with making. Thechemist can often pronounce on the genuineness orotherwise of a document, for if a document bearinga date earlier than 1861 is printed on esparto paperit is spurious, as is a document purporting to beprinted on wood-pulp paper before 1874. The

age of ink in writing can be ascertained with precisionby testing the surrounding paper and estimating theextent to which the soluble salts of sulphur andchlorine have permeated it. For periods over twoyears the chemist uses the older method of studyingthe formation of the resinous deposit, and thedifference in age between two sets of writing on thesame paper can be distinguished if one is less thanten or twelve years old. Dr. Mitchell, in theseand other examples, brought forward ample evidencewhy the forensic chemist should be recognised as an

independent ally of the medico-legal expert and why,although he is neither a doctor nor a lawyer, he iscertainly not a layman in the medico-legal world.

CARCINOMA TELANGIECTATICUM

THE clinical appearances and prognosis of cutaneouscancer are affected not only by the type of the growth,but also by the nature and plane of the cellulartissues it is invading. A spread in the lymphaticvessels, for instance, with a consequent block in

lymphatic drainage will lead to exudation and localoedema of the peculiar solid type which the Frenchhave termed cancer en cuirasse, or peau d’orange.Of equal importance and interest, though less oftenobserved, is the result of selective invasion of thecutaneous capillaries and smaller blood-vessels. Sucha case, illustrated in natural colour, has lately beenreported by Dr. F. Parkes Weber. It concerns

a woman of 48 who was operated on for carcinomamammse in October, 1932, and died from secondarydeposits in the pleura and elsewhere in May, 1934.The illustration brings out the localisation of theskin changes in the left flank, but hardly suggeststhe telangiectatic changes, due, as histologicalexamination eventually proved, to vascular involve-ment by carcinomatous cells. It appears that thesmall telangiectases are characteristic of this form ofmalignant invasion, and if this is so there is everyreason to support Dr. Parkes Weber’s argumentthat the name suggested by him, carcinoma telangiec-taticum, should supersede that devised for similarcases by H. Kiittner, of Breslau, and C. Rasch, ofCopenhagen-viz., erysipelas carcinomatosum, or

erysipelatoid carcinoma.

FREE FALLS IN SPACE

IT was formerly assumed that a free fall of over100 feet produced unconsciousness or even death ;but the use of the parachute, and " delayed parachutejumps " in particular, have disposed of thisidea. Delay in pulling the ripcord of a parachutemay be thought necessary for either of tworeasons : first to avoid entanglement with theaeroplane or collision with other jumpers, andsecondly in descents from extremely high alti-tudes. Captain H. G. Armstrong, of the UnitedStates Medical Corps, points out 2 that a jump from30,000 feet involves the loss of the jumper’s oxygensupply, and that if he opens his parachute at oncehe may lose consciousness or die before he gets toa level at which he will recover. He uses this asan argument in favour of a rapid " free fall" forthe first few thousand feet. But while we may agreethat a pilot opening his parachute at 30,000 feet,without using oxygen, would probably become

partly or wholly unconscious during the first fewminutes of the fall, it is generally believed in thiscountry that in such circumstances a fit man wouldlater recover consciousness, probably before reachingthe ground. On the other hand, Armstrong’s con-tention that in a free fall to about 20,000 feet aparachutist would retain enough consciousness to

open his parachute is borne out by experimenthere, provided no great effort has been entailed ingetting clear of the aircraft. His suggestion that ifit should be necessary to jump from an aeroplanetravelling at a velocity of the order of 360 milesan hour the pilot should not open his parachutetill he has lost almost all horizontal velocity is sound

1 Internat. Clin., 1935, vol. iii., p. 145.2 Jour. Amen. Med. Assoc., Oct. 5th, 1935, p. 1107.