Page images
PDF
EPUB

witnesses, how far the case has been carried by his statements. In cross-examination, properly conducted, he will have been questioned as to alternative hypotheses or possibilities, and it is part of his duty to show by his answers that he has taken them into account, and to explain by what processes of exclusion or exhaustion he has arrived at his ultimate opinion..

A court ought to consider with respect the opinion of any professional man, speaking out of special knowledge, so far as he can satisfy it that his opinion is well-founded, and supported by sensible and cogent reasons. He is conversant with details not within the ordinary knowledge of laymen, and he ought to be able to make clear to a court the points on which the decision has to rest. On the other hand, a court ought not to pay any superstitious or abject deference to his opinion simply because he is a doctor, engineer, chemist, or what not. Nor (at least, with me) would mere titular eminence avail much, unless there were also present strong and well-founded reason and judgment. A judge sweeps away readily enough an ineffective argument of counsel, and, when he is satisfied that he has been made acquainted with the point at issue, he is entitled to do something similar with skilled evidence.

It is, unfortunately, true that some counsel are careless or impatient of mastering medical points; but it is the business of the solicitor-who has digested the case from its inception, and ought to be alive to all those points—to see that the advocate has them brought fully under his notice.

The question of consultation between the medical witnesses on both sides is interesting, but as a solicitor I should object most strongly to such a course. As the legal representative of my client, I should desire to feel that the client's doctor was similarly his medical representative, so that in preparing the case for trial I could have recourse to the doctor on all important points, and discuss with him, without restraint, all the aspects of the case, whether favourable or not. I should inevitably feel some restraint if I knew that, after seeing me, the doctor was off to meet adverse parties to

engage in a conversation which must involve some disclosure of my case to my adversary. Moreover, in such a consultation of opposed witnesses, an ordinary practitioner might have to meet some exalted member of his profession, who by his prominent position might overbear the ordinary attendant, and yet the humbler man might be the better and more reliable witness. But my chief objection is that preliminary consultation must inevitably bring about a toning-down of the questions in difference, a give-and-take arrangement of the evidence to be subsequently given, and a certain weakening and dilution of the medical testimony all round. If the case is to be tried at all, the evidence should come out in the precise form in which the witnesses themselves wish to give it, and any criticism and modification should develop from the clash of battle itself in open court. One's best witness could not possibly be strengthened--and must in many cases be weakened—by chaffering with an opponent on contested points before the trial. A client is entitled to have all his chances fought out, and not to run the risk of having them whittled down beforehand. If I am to strike a blow on his behalf, I should have all possible force behind it. If the blow misses or fails, so it must be, but it ought at least to be firmly struck.

I am conscious of the contradictions constantly met with in professional evidence, some of which are humiliating to all concerned, some even ridiculous. Each of us has sometimes heard statements gravely made which passed our understanding. But in discussing the question here, I am bound to assume that a doctor is at least honest in his opinion ; and that, while putting on the facts before him a construction the most favourable to his patient, he will not degrade himself by going against light and knowledge. Some men have, no doubt, been known to forego some self-respect by giving an untenable opinion for the sake of a fee, but one generally finds that a professional man values his reputation too highly to place himself in a position so false that he knows he must go down like a ninepin before a shrewd question from the adversary.

These observations do not dispose of the idea of an assessor being employed ; they only show that a doctor in the case is not the man to act as such assessor. In cases, for instance, involving examination of the conduct or procedure of medical men or institutions, a coroner occasionally summons an outside professional witness, to whom questions may be addressed which would be ineffective if put to the person immediately concerned. An outside witness so called serves the purpose of an assessor, as he is a witness for the court, although, in the legal sense of the word, an assessor does not give evidence.

Without discussing at length the question of Dr. Freyberger's appointment as pathologist, it may be stated that in Birmingham the practice of the coroner is to assume that a medical man reporting a case is capable of making a post mortem examination if required; and that in cases involving a criminal charge two medical witnesses are summoned.

SOME REMARKS ON THE DIAGNOSIS OF SCARLATINIFORM AND ERYTHEMATOUS ERUPTIONS. *

BY A: DOUGLAS HEATH, M.D., M.R.C.P., Casualty Assistant Physician, General Hospital, Birmingham.

An apology is usually given by the reader of any paper before this society for the subject chosen by him, and, as such is the custom, it would be well for me to adhere to it.

In the search for a subject, we are often lead to attach a false importance to matter which, though of interest to ourselves, possesses small attractions for others. It is a knowledge of this fact that has led me to draw up a few descriptions of common rashes, in the hope that a useful comparison of experiences may be brought out in the discussion to follow

this paper.

No problems in diagnosis are much more difficult than some of the scarlatiniform and erythematous eruptions, and yet a mistake in diagnosis may be attended with very unpleasant results both to the patient, his friends, and his medical adviser. The rashes of the exanthemata are for the most part ably described in numerous medical works, and sharplydefined distinctions drawn between them, and yet what a number of atypical cases we meet with in practice which do not conform to our carefully-learned types.

Some eruptions also-German measles, for instance—are very quickly developed and equally quickly fade away, and if not seen in all stages are exceedingly difficult to recognise. It is also most important when a rash breaks out in a patient in hospital, or in a child at school, that the nature of the rash should be made out as quickly as possible ; otherwise, infection of others may be quickly brought about. Many large institutions now promptly isolate any doubtful eruption, and await events until a positive diagnosis can be made.

*Paper read before the Midland Medical Society.

There is no doubt that very mild scarlet fever and epidemic roseola are sometimes extremely alike, and time only will decide the diagnosis. I have known instances where several medical men have all held different opinions as to a particular rash, and have known men of great experience call an epidemic scarlet fever, where others of equal eminence have diagnosed roseola. It seems, therefore, to me that I shall make my future remarks on other eruptions more clear if I draw your attention at first to the rashes of the exanthemata with which we are now most concerned-scarlet fever, German measles, and ordinary measles.

The rash of scarlet fever is of a very bright brick-red colour, and appears first on the front of the chest, neck and upper arms. The eruption spreads downwards, and is fully developed in about two days. Either at the end of that time or a day or two later it begins to fade--first in those regions where it first appeared—and has generally completely disappeared at the end of six or seven days. The rest of scarlet fever is made up of two elements-(a) very closely-set minute red papules, and (b) an erythematous blush surrounding them. I have sometimes seen the rash much more papular than is usually the case.

As a rule, the typical punctiform eruption does not occur an the face. If it does, the forehead and temples only show it. The face is intenseiy flushed, especially on the cheeks, but the region around the mouth is left quite pale. Over the flushed surface of the face is soon developed a fine powder-like desquamation looking something like the bloom on a peach. This appearance is most suggestive of scarlet fever. Desquamation, which is usually well marked at the end of seven days, first begins on the face, neck, and chest, and is usually not general until the end of the second week.

It is on the trunk, limbs and neck that the most characteristic desquamation occurs. Here the fine flakes of epidermis are thrown off in thin lamellit, which have a worm-eaten or

pin-hole appearance, due to the mechanical friction on the summit of the papule, which forms the centre of each little portion of the eruption. This desquamation is most pasily seen in a mild case where the eruption has been most

« PreviousContinue »