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103 degrees; pulse, 120; respiration, 28. There was extreme general tenderness on pressure over the abdomen, with diminished liver dulness and resonance in the flanks. The knees were drawn up; he was very restless, with muttering delirium. His face was drawn and anxious; there were sordes on the teeth, and his tongue was dry and cracked. The abdomen was so rigid that the spleen could not be palpated. No doubt was entertained that he had been suffering from typhoid, and that perforation had occurred; but, after a consultation, it was decided that he was too ill to bear an operation. The next day he was thought to be steadily sinking; the pulse was quicker and wiry, but not irregular, and the temperature ranged from 98 to 100 degrees. The abdomen was hard and rigid, very tender, especially on the left of the umbilicus, but pain was induced on pressure anywhere. That evening he was very restless, and a copious motion followed the adminstration of an enema. Next day he remained in much the same condition a state of profound asthenia, in which he had lost command of his sphincters. He complained of abdominal pain, was very restless, and had to be watched constantly; pulse was rapid and dicrotic; face very anxious. On the following day he was about the same, restless and delirious, and attempted to get out of bed; the abdomen moved very little on respiration, but the rigidity of the abdominal wall was not quite so marked. On the following day he was no worse, except that his face was more pinched and a trifle more anxious; the abdomen was still distended, but not so much so as at the time of admission; tongue dry and brown; pulse still rapid and wiry. On the following days it was noted that he was said to be in a state of increasing weakness and exhaustion. Then pulse began to get slower, and his abdomen became less distended, moved a little on respiration, and he seemed to be improving generally. Very slowly all bad symptoms disappeared, and he ultimately became convalescent, leaving the hospital ten weeks after admission for a sanatorium.
These two cases-in each of which I have no doubt perforation occurred are at least proof that a certain number
of cases will get well without operation, but they form a very small proportion of recoveries compared with the deaths that have occurred in my practice; and if Dr. Kean's statistics can be corroborated by the experience of others, I have very little doubt that his dictum "that all cases of perforation should have the benefit of operative interference "should ultimately become an axiom of practice. It would be fortunate indeed if one could estimate the probability of the occurrence
non-occurrence of perforation in our cases. Unfortunately, so far as my experience goes, this is not possible, and some of the most distressing cases we have to deal with are those which occur in cases in which we believe that convalescence or even complete cure has taken place. Such a case is that of a patient, aged thirty-eight, who was under my care in the General Hospital in February of last year. He was a remarkably powerful and vigorous man, who had suffered from a moderately severe type of the disease. He gradually improved so far that in the seventh week he was said to be quite well, but his temperature still varied a little, though only on two occasions did it exceed the normal. In the eighth week, after his temperature had, with these two exceptions, been normal for twenty-two days, and his diet had been improved so far that he was taking a little fish and milk pudding, he was one day found with greatly distended abdomen, which was rigid and tender all over; his pulse ran up to 126, and his temperature to 101 degrees. His face was anxious and drawn, and he seemed to be greatly distressed. Perforation was diagnosed, and an operation was performed, which revealed very dark-red angry coils of intestine, with masses of fresh lymph tending to mat the coils together. A small pin-head perforation was discovered and stitched, probably at the lower end of the ileum. He seemed to be doing pretty well, but one week after the operation he sank and died. The autopsy revealed general peritonitis; the operation wound had held together, but another larger perforation, the size of a threepenny bit, was discovered. This came as a great shock and surprise to me, and emphasised the fact, which should never be forgotten, that no patient is
safe in typhoid until he is able to take ordinary diet with impunity; but the result of operation emphasises also more emphatically what has always appeared to me to be an argument against operation, namely, that where one perforation has occurred, the conditions are probably favourable to further perforations in other places. These cases have all exhibited distension of the abdomen as a sign of perforation, but I have had several other cases in which perforation has occurred without any distension; and it seems likely that the presence or absence of general distension must depend entirely upon the presence or absence of adhesive peritonitis about the seat of the puncture. To distension, therefore, as a sign of perforation, I should be less disposed to attach importance than to rigidity of the abdominal wall and to tenderness on pressure. However, in an article on this subject in the January number of the Annals of Surgery, Drs. Harte and Cooper state that in 271 cases which were operated on, it was noted that the perforation was single in 236, and multiple in 35. Though the percentage of death is still very high after perforation, namely, 75 per cent., it is lower than in the cases in which no operation is attempted; and I am disposed to think that it would be my duty where I believed perforation had occurred to recommend operation.
BY HERBERT MANLEY, M.D.
THE advent of the legal vacation suggests that perhaps to some readers a short essay on the present position of medical evidence may be neither unwelcome nor unprofitable.
In considering the subject, one is met with the fact that, as a rule, the doctor is not considered a satisfactory witness. There is often some want of harmonious understanding, real or apparent, between the examining counsel and the witness. This may arise from several causes :
1.-Medical evidence is essentially the giving of an opinion, sometimes based upon facts, as after a post mortem or other examination; sometimes founded purely upon theory and the experience of the witness in other similar cases. The value of such evidence to the counsel is either the value of the grounds upon which the opinion is stated to be based, or the eminence of the witness (not always an easy matter to assess).
2. It is exceedingly difficult to clothe strictly scientific terms in popular language, and, unless the barrister or solicitor engaged in the case is willing to master the exact medical point at issue, there is a danger that the true meaning of the evidence is lost.
3. There is a disposition, for which the profession is partly to blame by reason of its own obscure diction, on the part of judges and counsel to minimise the value of evidence of this type as being speculative, lacking in definite terms, and unreliable.
It is perhaps not altogether wonderful that medical men are such bad witnesses, seeing that little or no endeavour is made to teach them their duty to the State during their curriculum; and further, that when they are launched into practice, they find all sorts and conditions of men, from the police-officer upwards, endeavouring to get out of them something without paying for it.
Without dwelling further upon these unpleasant topicsthe mention of which was inevitable-let us pass to other points in medical evidence. The cases in which medical men are concerned are either civil or criminal. To take the latter first-It must be admitted at once that in all criminal cases the medical witness, even though he may appear for the prisoner's case, must observe an absolutely judicial and impartial attitude. Nothing can be more fatal than for a medical expert to adopt the position necessarily assumed by the police of securing a conviction at all hazards. It is manifestly his duty, in stating the facts of which he is possessed, to state them all, and not merely those which may tend to convict the prisoner. It is not always easy to induce the prosecuting solicitor to see the case from this point of view, while an interview with the prosecuting barrister is almost unheard of. There are, of course, exceptions to this state of things, but they are rare. The medical expert should consider himself as the medical assessor of the judge, and if he makes this position plain to his lordship, due value will be given to his evidence.
Much complaint has recently been made of the Coroner for South-East London and his expert, Dr. Freyberger. It cannot be denied that the bulk of this complaint is wellfounded. Oddly enough, no one has been brave enough to discover the real reason why a medical expert had become necessary. The true grievance against Mr. Troutbeck is this that he has elected to rely on the post mortem evidence of an expert, and to ignore the clinical evidence of the ante mortem practitioner. It is not given to all men to make a post mortem with accuracy and tidiness; many men have never made a complete post mortem examination until they are suddenly called upon by a coroner after they have been a few months in practice. Is it fair that to such haphazard anatomists should be left questions upon which the hanging of a fellow-creature may depend? The proper course undoubtedly is to appoint, as far as circumstances will permit, a medical pathologist to every coroner's court, whose evidence should follow the evidence of the general practitioner