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fntercst in the liver has been furtlier stimulated bythe more exact classification of cases of jaundicewhich are now very generally recognised as falling into ’’,three classes: (i) those in which there is grossmechanical obstruction to the hiliary channels; (2)those in which the liver cells themselves are so dis-ordered that the proper exeretioll of bilirubin from theblood cannot be accomplished ; and (3) those in whichthe jaundice is the consequence of excessive hæmolysis,the blood being saturated with bilirubin of extra-

hepatic origin. Intent on the elucidation of such

problems, laboratory workers have long sought forchemical tests wliieli- may demonstrate pathologicalchanges in the liver cells, and hence any defect in thegeneral physiological capacity of the liver. such testshave been suggested in great numbers, and it must berecorded that they have usually had but a transitorypopularity. Almost as fast as they are devised they fallinto disuse, and it should be placed to the high creditof medical research that improved and novel testsare investigated perpetually by eneretie workerswho refuse to allow disappointment to convert themto pessimism.

In our present issue we print the results of investiga-tions into two liver tests which, if not entirely novel,have not perhaps received the attention in this countrywhich they appear to deserve. Essentially there isno great difference between the two, for in each asimple sugar is administered by mouth and the testconsists in ascertaining the change, if any, which occursiu the concentration of sugar in the blood at subse-quent half-hourly intervals. In the test described byDr. D. T. DAVIES galactose is employed. This is givenin a dose of 40 g. dissolved in 400 c.eur. of water,samples of veiioiis blood being collected at half-

hourly intervals for several hours afterwards. Inaddition to these blood samples, the urine is also

oollectecl, though the conelusion of BAUER, one of theGerman observers, that galactosuria was the one

positive sign of abnormal liver function, is not fullyborne out by the latest investigations. The blood-

sugar curve has, in Dr. DAVIES’S hands, proved moreuseful, no great rise in this curve being observed savein those cases where the hepatic cells had been grosslydamaged. Thus normal persons, patients with grossobstructive jaundice, and subjects with perniciousanaemia and acholuric jaundice, alike showed little orno rise in the blood-sugar after the ingestion of galac-tose; whilst those with catarrhal or toxic jaundice,cases of malignant disease with secondary deposits inthe liver, and cases of cirrhosis following syphilis orchronic alcoholism gave very definite increases in the

blood-sugar after galactose owing to the serious

derangement of the givcogenic function of the liver. Mr.GORDON KING has employed lt-vulose, of which sugarlie gives 45 g. in 100 c.em. of water to the fastingpatient. Subsequent blood analyses again were usedto determine the curve of blood-sugar. In 53 cases

investigated it was found that only those subjectsin whom gross damage to the liver cells was presentshowed a marked and continued rise in the concentra-tion of sugar in the blood. It is clearly too soon todiscuss the ultimate value of these tests, thoughany attempt to give a firmer outline to the

vague country of " liver disorders " is to becommended. The transitory nature of our confi-dence in the virtue of certain other tests has

already been alluded to, and is exemplified in theinteresting article by Dr. ERNEST BULMER who,in the current number of the Quarterly Journal ofMedicine, records the unsatisfactory results which hehas obtained during his investigation of the brom-sulphalein test. In this test, devised by ROSENTHAL,

a dye, bromsulphalein, is injected into a vein, andthe amount of such dye remaining in the bluod-serumhalf an hour later is estimated by a relatively simplecolorimetric test. Earlier investigations appeared topromise that only in cases of defective-liver funetionwould there be marked retention of the dye, and indeedthat the degree of retention would give an accurateindication of the extent of hepatic deficiency. FromDr. BULMER’S results it would appear that such hopeswere groundless, and that there ia too gross a marginof error to leave much practical utility in the tet.Somewhat similar disappointment has been experi-enced in the case of the test associated with the nameof Prof. H. van den BERGH. The hope that this testwould supply a ready method of differentiating thevarious types of jaundice has not been fulfilled,though, as Dr. DAVIES points out in his article to,day,it has proved of value in estimating the degree ofbilirubinsemia.The critical clinician, when reading through the

protocols of inquiries such as those to which we hereallude, is apt to point out how little they add to theinformation which is already obtainable by carefulclinical examination. The degree of jaundice can be asdelicately estimated bv the human eyes as by almostany laboratory test ; the size of the liver and itconsistency give information as precious as any thatthe biochemist can bring forward ; and it is indeed tothe clinician that the laboratory worker turns wlwuseeking the interpretation of the subtleties before him.But to recognise these facts is not to disparage thechemists’ efforts, for most important results have

already been obtained of which the more preciseclassification of jaundice is an example; and if thelaboratory now settles the diagnosis in but one case ina hundred, that one is to the good and is the probableforerunner of further diagnostic success.

THE LIMITATION OF EXPERT EVIDENCE.Ix the course of a case which has occupied his

judicial attention for several weeks, Mr. JusticeTOMLIN has ruled that he will not hear more thantwo expert witnesses on either side. The decision,discussed by a legal correspondent upon another page.has interest for the medical profession which furnishesso great a proportion of the expert evidence given incourts of law. It may cause some apprehension too.The medical practitioner may find himself involvedfrom time to time in litigation in which professionalnegligence or malpraxis is alleged : will he not beprejudiced if the court curtails his right to summonall the expert witnesses he may consider necessary iEven in a civil action, still more in criininalproceedings, any such curtailment might amount toa denial of justice. We can only assume that nogeneral interference of this nature is intended;indeed the circumstances in which the learned judgedelivered his ruling appear to have been exceptional.A colliery company had asked the Court of Chanceryto restrain the Swansea Corporation from filling acertain reservoir with water on the ground that, if thecorporation carried out its purpose, the mine workingswould be flooded. The case had occupied 26 dayswhen Mr. Justice TOMLIN made his pronouncement;it has since lasted a further fortnight, a" no doubthe foresaw, and it is not yet ended. He has

adjourned the action for a month in the hope af

making progress with the other cases in liis list whichwere promising to be indefinitely postponed. Alreadyexpenses have been heavy ; the existing costs are

estimated at £40,000. One expert witness, called on

401

behalf of the colliery company, has been 11 days inthe witness-box, and his evidence, it seems, is evennow not yet concluded. In these circumstances itis nut surprising that the judge does not desire to

hear several additional experts whose, evidence willtravt-I over the same ground ; if lie is to limit thewitnesses for the plaintiifs, lie must also limit thosef(lr the defendants. -

How far is it likely that the judge’s ruling would beitioplied to litigation in which a medical practitioneris personally concerned as plaintiif or defendant ’?Here two points may be borne in mind. In the first

place a Chancery judge sits without a jury. Partner-ship disputes between doctors, in which professionalconduct might he an issue, might conceivably findtheir way into a Court of Chancery ; but the normalcase in which negligence or malpraxis is alleged willusually be tried before a jury. When there is a jury,it is for the jury—not the judge-to decide the facts.If so, the jury—not the judge-is entitled to saywhen sutlicient evidence has been heard upon a

particular point. The attitude of a juryman issometimes unfathomable. He may discount theevidence of all the experts impartially, or he mayreckon its weight by the relative numbers of the

experts rather than by their relative qualifications ;be Ulay even think, if the case is tried in the country,that his own local doctor is a better man to followthan some stranger from London. But he is not tobe told that lie must only hear two experts and notthree, or three and not four. In the second place,it must be remembered that one or two expertscannot always cover the whole of the ground or dealwith every technical aspect. The Swansea Corpora-tion, protesting against the ruling under discussion, urged that it might wish to call the evidence of

experts in the separate subjects of mining, watersupply, and geology. The judge answered that hewould not limit the number of witnesses if satisfiedthat "by reason of special circumstances" justicecould not be (lone without hearing other experts ;and, in any case, additional witnesses could be called.even though experts, to speak to matters which theyhad personally seen. The argument of the SwanseaCorporation would often apply where a case turnsupon medical evidence. Recently, for instance,where a doctor was charged with performing an

illegal operation, it was indispensable for the defenceto adduce the evidence of expert pathologists,gynæcologists, and anaesthetists. It would have beenintolerable if the defendant had been restricted toa maximum of two experts.There are practical limitations upon the number of

witnesses already. Learned counsel, wlio advise

preliminarily what evidence is desirable and who areresponsible subsequently for the calling of theevidence, know better than to weary with vain

repetitions a tribunal which has already appreciateda point of fact or opinion. The expert upon whoseauthority the litigant most confidently relies is

generally the first to be placed in the witness-box ;when his evidence is ended, a sequence of lesserexperts will add but little. The taxing-master, too,contributes to the limitation of numbers, since it isknown that he may disallow the costs of superfluousevidence. But there are times when the risk of

repetition must, be run and when costs must be incurredwithout regard to their recovery. The defence of hisprofessional reputation is a cause in which a

practitioner must employ every resource. «Te cannotbelieve that judges will ever obstruct his right to.call into the witness-box every witness who may bedeemed necessary for that purpose.

Annotations.

TREATMENT OF STOKES-ADAMS ATTACKS.

Ne quid nimis."

FEW clinical incidents are so dramatic as a Stokes-Adams seizure. The suddenness of the onset, theurgency of the symptoms, and the possibility of a fataltermination together create on the observer an impres-sion never likely to be forgotten. The unexpectednessof the calamity is not infrequently intensified by thefact that before the first seizure the patient has hadlittle cause to suspect the existence of any seriousderangement of his circulatory mechanism, and mayin fact have led an active life. Even physicalexamination between attacks sometimes reveals butlittle evidence of morbid changes in the heart ; for

though in most cases some grade of heart-block ispresent, instances do occur when even this is lacking.The mental anguish of these patients is often pitiful,and when their seizures follow one another in rapidsuccession they live in constant dread of impendingdeath, hardly daring to move a muscle for fear ufprecipitating the next, and possibly the last attack.As in all paroxysmal conditions treatment resolvesitself into abortive and preventive measures. Thelatter are the more important, for in the greatrnajority of cases individual attacks are of shortduration. Ventricular asystole implies not only thatthe normal impulses from the auricle are failing toreach the ventricle, but also that the lower centresin the heart have not set up an independent rhythm.It is not surprising therefore that Stokes-Adamsseizures should most frequently occur during theunstable phase when partial heart-block is tending tobecome complete, or when complete block is revertingto normal rhythm. The increased incidence of attacksduring such transition periods is well illustrated by acase recorded by Parkinson and Bain in our culumns 1in 1921:. Failure of the auricular impulse to reach theventricles may sometimes be due, in part at least, toan increase in vagal tone. L’nder these circumstancesatropine may relieve the condition, but m the treat-ment of the Stokes-Adams syndrome the therapeuticeffect of this drug is as a rule disappointing. When,on the other hand, the block is due not to vagalintluence but to some structural lesion of the bundleor to damage caused by some toxic agent, the rationalline of treatment is to endeavour to increase theexcitability of the muscle of the ventricle itself. Thismay sometimes be achieved by subcutaneous injec-tions of adrenalin (5 to 10 minims of the 1 in 1000solution). Complete heart-block is sometimes abolishedby adrenalin, whilst in other cases, although theblock remains unaltered, ventricular standstill is

prevented. S. A. Levine2 has recently reported aremarkable case in which on two occasions Stokes-Adams attacks lasted for several minutes, and ventri-cular activity was re-established by injecting adrenalindirectly into the heart. The most recent therapeuticagent employed in this condition is barium chloride,a drug known to increase the excitability of theventricle under experimental conditions in animals,and A. E. Cohn and Levine have shown that clinicallyit sometimes appears to prevent recurrence of thesyncopal attacks, and recommend a dose of 30 mg.four times a day by mouth. Unfortunately neitheradrenalin nor barium appears to be etïicacious in allcases, though in the present state oE our knowledgethey offer the best prospect of preventing the attacks.

INTELLIGENCE OF THE NEGRO.THE problem of the negro is a hardy perennial in

the United States, and it was inevitable in a countrywhere so much work has been done with intelligencetests that their aid should be invoked in order todetermine whether his assumed racial inferiority is

1 THE LANCET, 1924, ii., 311.2 Boston Med. and Surg. Jour., 1926, cxcv., 1147.