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As the patient's pain was constant, his strength gradually lessening, and because his father had died of encephaloid cancer of the knee following an injury, I told his sister that I thought it very probable that he had a cancer, but that we could not find any enlargement to prove the diagnosis,
Light pressure over the triangular area caused severe pain, but deep pressure did not hurt as much, and when by abdomino-rectal touch I made both hands meet, I gave up my diagnosis of cancer.
A little later their family physician returned, and took charge of the case. He said the patient had entero-colitis and treated for that. As the patient continued to fail and finally died, I returned to my old diagnosis of cancer.
At the autopsy all the abdominal organs were nearly normal, but upon the anterior surface of the lumbar vertebra there was an encephaloid cancer, extending from the diaphragm to the last lumbar vertebra, an inch or two thick and wider than the bodies of the vertebræ. It surrounded the aorta and vena cava and displaced the former to the right of the latter.
I report this case simply to impress upon our minds the factwhich is too often proven too late for our good--that in all cases where the patient has reached middle life and there is present continuous pain and tenderness, and no improvement, we should at least suspect malignancy.
As this man and his father both died from an encephaloid cancer, which was preceded by an injury, it would go to prove the heredity of carcinoma, and that injury aided or was the exciting cause of the onset of the cancerous growth.
By G. LAW, M. D.,
Greeley, Colo. Suits in courts of law, criminal or civil, are liable to be brought against any member of our profession, at any time with or without adequate ground. In either case the results, whatever they may be, are to the individual so arraigned generally more or less disastrous. Hence it is necessary that the medical man should know something of his own rights, and of the best methods in vogue of defending them. I propose, however, to take up only some of the points in the method of the doctor's defense on actions against him for alleged malpractice, ignoring in this paper the important one of crime. That side of the subject diverges very widely from the branch I have taken for consideration, and, furthermore, good men and prudent men in our profession do not premeditately commit crime, and the other class usually know how to defend themselves; hence the dangers in this direction to us are not great.
*Read before the Weid County Medical Society, May 25, 1896.
Preceded, or not, by a communication from Swindle-em & Co., Attorneys-at-Law, in which demand is made for the amount sued for, the sheriff visits the doctor, and taking a formidable looking type-written document from his satchel begs leave to place it in the doctor's hands. In this the doctor finds that someone solemnly swears that he, the doctor, has conducted himself "so ignorantly, carelessly and negligently,” in the case set forth that the plaintiff alleges and believes himself to have been injured, maimed and damaged beyond recovery, for which he prays the honorable court to compensate him in sums of money so preposterously large that, if granted, could only mean financial ruin to the unfortunate doctor and such professional and social disgrace that he, the doctor, may perforce be driven out of his business and out of the community in which he dwells.
Hence it behooves us to stow our minds with at least an elementary knowledge of medical jurisprudence in all of its branches. After the service of the complaint of the plaintiff's charges the defendant must make replication, inside usually of ten days, in which he makes general or specific denial. This he had best do through his attorney. If he fails to do so the case will, of course, go agalnst him by default. To the defendant, the selectiou of an attorney is a very important matter. Lawyers, as a rule, have exceedingly vague and misty conceptions of what constitutes the sum of knowledge of a doctor "possessing ordinary knowledge, ordinary skili, and exercising ordinary diligence, in the practice of medicine and surgery," having reference to the ordinary standards of skill, efficiency and proficiency at the particular time and place and section in which all the occurrences transpired. The defendant will have to thoroughly study his own case, and then impart that knowledge to his attorney for presentation to the court, unless he takes the dangerous course of appearing in his own behalf. His attorney will ask him to give all the facts, pro and con, general, medical and surgical, that have a bearing on his case. Probably he can state those of a medical or surgical character quite glibly, but cannot at once remember whether Gross, Hamilton, Stimson, Ashhurst, or who in particular is his authority. His lawyer will tell him that it is not sufficient to know the facts; he must be able to point out the authorities. Lawyers do not have to carry their knowledge ready for
an instant application as do doctors. With the aid of the index rerum they look up the law and court decisions as applicable to their cases.
If our case is a severed artery, we have no time to go to our libraries and consult the latest “fin de siecle" work on surgery. If our case is a suit for alleged malpractice we must study it most thoroughly from the lawyer's standpoint, and in the legal way from that of the doctor and surgeon. The defendant in civil malpractice suits, had best find all the facts in any way having the remotest bearing on his case, whether favorable or otherwise and carefully commit them to paper. The study of this paper by his attorney then becomes of the utmost importance. The case is probably surgical. Medical errors, medical carelessness, medical negligence, if not too grossly palpable, are likely to be hidden under the ground or in other ways made intangible. In any case the defendant must rub up his knowledge of anatomy until he is text perfect. He must impart this knowledge to his attorney, for without it that individual may not be able to trip up the glib and partisan professional witness for the plaintiff, whose damaging, and perhaps unfair and one-sided, testimony has gone to the jury with telling e ffect against the defendant.
The plaintiff must divine, guess, or otherwise find out as nearly as possible, just what the plaintiff will say on the witness stand, provided he appears in his own behalf; also what his father, mother, sisters, brothers, friends and foes may say. He can rest assured that friends of the plaintiff are liable to go as near to perjury as the plaintiff's attorney will allow them in their zeal to win the cause. The defendant therefore should, in his mind, place the plaintiff on the stand and then conceive himself in the place of the plaintiff's attorney, the bland, unctuous, self-confident Swindle-em bringing out this testimony in the lawyer's most artful, impressive and telling manner. All the witnesses for plaintiff should in like manner be made to give their testimony. Next, cross-examine them carefuliy, writing down all this imaginary trial. Defendant will follow, of course, with his own testimony and that of his witnesses, both lay and professional. Changing places with Squire Swindle-em, he will as nearly as possible cross-question himself and all his witnesses in the matter, manner and method of that sleek individual. In the matter of sifting his own evidence and that of his witnesses, the defendant cannot be too careful in scanning all of its weak points. Defendant should carefully prepare the hypothetic questions he expects to propound to his professional witnesses, and endeavor to anticipate the way the plaintiff's counsel will probably try to offset this testimony. Finally, all the evidence includin ļa
buttal being in, all supposed objections and exceptions taken and carefully noted, together with the court's supposed rulings, defendant will proceed to argue his case before the jury. Next, he will prepare the judge's charge to the jury from the plaintiff's standpoint, also that from the defendant's side. It may not be generally known outside of legal circles that the papers, called charging the jury by the judge, are not prepared by that functionary, but are compiled by the attorneys for plaintiff and defendant and submitted to the judge, who carefully studies them and then eliminates or adds as he deems proper; and these amended statements of the law in the case goes to the jury as an emanation from the judge for the guidance of the jury in their deliberations.
This complete study of the case by the defendant, under the supervision of his attorney, in which everything has been written out and copied legibly by a typewriter, will be found of great use when the real fight in court comes on.
It is true everything will not then occur in quite the manner so carefully planned. Still, a carefully arranged campaign in war, notwithstanding many details have to be modified every day of its duration, is much more likely to be successful than one undertaken in a haphazard way. Defendant will look up all his professional authorities and mark the places in the books, and have an index, with subject, author, page and paragraph, so that instant and unerring reference can be had. Now, books cannot be read as evidence, direct, in court. Books are not under oath. Books are not the statement of a responsible party under oath, yet books are read in a roundabout way and serve as evidence on technical and professional points at issue in the courts of law. Defendant's attorney, or plaintiff's attorney either, may ask a professional witness, either in the direct or cross examination, what a particular surgical writer said on some definite point having a bearing on the case. If the witness has not been coached for this particular thing he will hardly remember the precise language of the author referred to. If he does remember, the evidence sought is obtained at first hand; if the witness does not quote precisely the exact words of the author the examiner has the right to read them from the book, for the purpose of correcting the witness. The witness should be asked if he endorses what the author says. Books that have a bearing on the case thus become to all practical intents witnesses that cannot be impeached, nor their value nullified by a trick of cross examination as may be the testimony of the most reputable witness. Defendants in suits for alleged civil malpractice, after the thorough study of their case as indicated, will have arrived at the salient points upon which the decision must rest. This enables them, by the help of their attorney, to not only formulate the hypothetical questions to be propounded to their own expert witnesses, but to essentially anticipate the substance of what the plaintiff's lawyers will propound to their experts. Now is the time to prepare as many rods as possible, to be kept in good pickle, with which to castigate the partisan expert, if such an one should appear in the case. Get all the information possible about all the witnesses, both for plaintiff and defendant. Ascertain whose testimony, if objectionable, can be nullified or impeached, and how. Your attorney will thereby be the better able to protect your own witnesses and discount those of your adversary.
With all this preparation the defendant must, in addition, maintain the utmost reticence wlth reference to his case and his methods of conducting his defense. The manner and methods of prosecuting cases are so stereotyped that attorneys almost know to a nicety what that will be. Not so, however, with the defendant, if guided by a shrewd and careful attorney. Other things all being equal, the more novel and unusual the ethods of your defense, the more perplexing and difficult becomes the task of the rebuttal on the part of the plaintiff and his counsel. All these things should be most carefully attended to, and probably others also that do not occur now to my mind, but would occur to any plaintiff fighting for the hard-earned dollars and honors of more than half a lifetime. Young doctors, if poor, are rarely sued for malpractice. Attorneys for plaintiff in civil malpractice sults of course will cram with book knowledge of anatomy; however, unless they are carefully coached by some competent medical man, the knowledge consists mainly of anatomical nomenclature and only vaguely represents the structures, tissues and organs for which these names are made to stand. Defendant, being himself a medical man, should take infinite care that his attorney's knowlege of anatomy should be real. He, the attorney, should also be made to see the tissue changes wrought by traumatisms. A minute conception should be instilled in his mind of the manner in which living protoplasm is thrown into the breaches of continuity in severed tendon, ligament, muscle, skin or bone, and then cell by cell new scar tissue made to take the place of the lost substance. He should know that the lost substance is not always replaced by identically the aame tissue, and never, except in the case of bone, with one of equal value to that lost. Defendant should instill into the mind of his lawyer a minute conception of the best teachings with regard to the manner in which the living tissues get rid of the effusions of blood and serum always present in the structures after injuries; and how morbific organisms,