Page images
PDF
EPUB

the medical profession and with the medical journals. Until we are in a position to, and do take the instruction of the public and of the laity out of the hands of laymen on this most urgent of medical matters we shall accomplish nothing. There is urgent demand, sociological, legal, individual and medical, that the investigation, consideration and treatment of narcotic drug addiction shall be seriously fostered in the spirit of worthy clinical disease study within the field of internal medicine.

It

One more very important matter. seems to me that the long standing medical reticence in the matter of information to the laity on medical subjects must be broken through in the case of narcotic drug addiction. About a year ago at a symposium of the New York Board of Health on the subject of Quacks and Quackeries, held at a meeting of the Medical Section of the Academy of Medicine, I read a paper on the "Evils of the So-called Drug Cures." In this paper I strongly urged that, as the individual practitioner cannot instruct the laity in the public press no matter how strong lay pressure is brought to bear upon him, without his being severely criticized by his professional brethren and his motives misunderstood, the medical profession through its duly authorized bodies should provide this instruction to the laity by way of the lay press. There is a crying need for the instruction of the public in matters of narcotic drugs, and this need must be met. The reticence of the ethical and legitimate medical bodies on medical matters of public interest often leaves the education of the public open to charlatans and quacks and is really the protection of charlatans and quacks in their practices.

The treatment of narcotic drug disease

is in its fundamental mechanism a legitimate part of and belongs within the province of internal medicine. On its being

placed there and being taught in a rational, ethical and non-spectacular manner depends the solution of the narcotic drug problem. In the long run it is to the medical practitioner-into whose hands will ultimately come the logical and proper handling of the bulk of narcotic addicts, and whose privilege and power it is to guide and form to a large extent the lay conception of medical matters that we must look for the real solution of the narcotic drug problem and the cure of the narcotic drug addict. It is to the medical journals and to the influence of their editorial columns that we must look for the broad education

[blocks in formation]

The problem of the medical expert witness in his personal equation and the solution of that problem is not to be found in the statutes of the State or Nation, or in the codes of ethics of medicine or law, but in the application of the square deal as between him and his neighbor, either because he is by nature just or because the exposure of his injustice puts an end to his practice of distorting medical truth.

The medical expert who merits the censure of the public is a creature born of medical conceit and legal ignorance and has had for his nurse an unscrupulous lawyer; a prominent New York lawyer once said that an incompetent or dishonest medical witness could not break into a legal case with a burglar's jimmy and, while this statement bears the marks of a "bull" it carries a world of truth with it; hence, whatever our efforts to rehabilitate the medical expert we may not hope to restore him to his former dignity and usefulness until and unless we have the earnest cooperation of the bench and bar.

The thoughtful lay citizen who seeks the betterment of his kind turns hopefully to the public press as the great teacher of the times and the earnest medical man who feels keenly the contempt in the public mind for the representatives of his order who appear in the courts turns hopefully help in correcting the conditions which and prayerfully to the medical press for

exist in the relation of medicine to law, a relation which was never so pressing or so important as it is in these times when, by reason of abuse, it has come to be the custom to insinuate a medical issue into a legal case, if at all possible, so as to cloud the issues of fact, whether those issues involve responsibility for crime, the capacity to contract for or dispose of property or the degree and permanency of injury, real or fancied, in an action in negligence, and because I have pride in the dignity of my order and because I realize the danger which threatens it from the prostitution of medicine in the

*Read before the 46th annual meeting of the American Medical Editors' Association, at New York City, October 18, 1915.

courts and because I have confidence in the sincerity and efficacy of the medical press, I welcome this opportunity to address your association and I am grateful to my friend Dr. Lewis, of American Medicine, for thinking of me. The medical press in this country is an untrammeled power for good, its editors are lovers of mankind by reason of their training and experience in medicine and they are big enough and broad enough to take a determined stand on this problem of the medical expert and powerful enough to make their censure reach the hearts of the medical and lay public and, while commending and encouraging the honest medical witness to deal fairly with his fellow citizens before the civil and criminal tribunals of the land will force the dishonest medical witness to mend his ways because the light of exposure and ridicule will make it dangerous and unprofitable for him to do otherwise.

I know the temptation is very great for a medical man on the witness stand to make display of his special knowledge before a jury or layman for, while the very nature of his life-work, and his heroic struggles with disease and death, clothes him with majesty when he enters a sick-room, he is conscious when he appears in court that he is an exhibit to be analyzed, diagnosed and indexed by a jury of laymen who, under other conditions, would stand in awe of his special knowledge and if he be not as careful to subordinate his pride and his personal equation to his sense of justice in the court room as he is to subordinate his pride and his sympathy to his sense of reason in the sick room he will fall into the error of making his partisanship do violence to the rights of his fellow-man and his victory over the opposing counsel who tries with paucity of medical knowledge to keep him in the narrow path of medical truth may prove disastrous to the medical witness and discreditable to his order for out of the encounter may be born a medical expert witness who under the shrewd manipulation of an unscrupulous lawyer will become the gunman of the medical profession and bring his whole order into disrepute and, to our humiliation as medical men be it known, this type of medical witness is in the minds of judge, jury and public, when a medical question is involved in a civil or criminal

case.

So far as the unfortunate victim of his act is concerned the man who flourishes a gun recklessly and shoots a bystander because he did not know it was loaded" is just as dangerous as the man who "packs his gun" and goes after his prey; there

fore, when a medical man takes the witness stand and qualifies as an expert he is charged with that degree of knowledge of his subject which a reasonably careful and prudent medical expert would possess or seek to acquire, and if he has evolved a theory in regard to a medico-legal case and has failed to submit that theory to careful analysis in the light of his own experience and the experience of others he must be judged by his fruits and his sin of commission may have as serious consequences for a litigant in the civil or criminal order as would the sin of commission of one who deliberately ignores a medical truth and testifies to a lie; let me illustrate this:

[ocr errors]

A man at a seaside resort, in a wet bathing suit, swinging by a wheel on an aerial wire stretched from a bathing pavilion to the ocean fell on the sands and dislocated his hip; he was in the hospital thirty days and home, convalescing, thirty days and after a heavy mid-day meal was found dead in his parlor; a physician, without an autopsy, certified to "paralysis of the heart from cerebral embolus" as the cause of death; by the time a civil action in negligence against the owner of the bathing house came to trial the diagnosis had developed this astounding detail-that "a plug of hemorrhagic material, arising at the site. of the dislocation (sixty days after date), had entered a vein and found its way into the artery leading to that center in the brain which presides over heart control, thereby producing paralysis of the heart,' a very startling theory for a medical man to contemplate in the light of his study of the circulation of the blood and the process of inflammation and repair, yet a very impressive theory for a lay jury to rule upon and a very difficult one for a lawyer to combat if I had not previously trained him in the circulation of the blood and the process of repair so that he was able to bring out on cross-examination the utter improba bility of any such plug existing sixty days after the accident, or being able to make its entrance into a vein without the aid of an auger or, granting the absurd hypothesis to this extent, being able to pass the pulmonary circulation with any greater ease than a half inch diameter eel could pass through a quarter inch diameter pipe and while a competent cause for death from chronic interstitial nephritis was evidenced by a urinalysis on the day of his admission to the hospital which persisted throughout his stay, the hospital record, material as it undoubtedly was and distinctly relevant to the issues involved was incompetent because the man who had made it was not

available to identify and interpret it and the defendant's only hope for justice in this suit for $50,000 was in the preparation of a hypothetical question which would enable me to answer that upon the facts in evidence and assumed to be true I could not state what caused the man's death because they were insufficient on the face thereof, which paved the way for a further question as to what, if anything, would render the facts assumed sufficient, and the answer "the findings of an autopsy as to the condition of the vital organs" when the further question why? enabled me to meet the medical issue fairly by describing the operation of organic disease of the heart and kidneys in causing sudden death and to submit among other theories the effect of cold air on a wet body rushing through it causing, in a nephritic, sufficient circulatory change to precipitate a slight uremic seizure which relaxed the bather's hold on the wheel and caused his fall and dislocation, and a fatal uremic seizure as the cause of his sudden death evidently impressed the jury as a more reasonable explanation, for their verdict was for the defendant and rightly so. I did not then and do not now believe that the plaintiff's doctor in that case was actively dishonest but that fine academic distinction could hardly have been appreciated by the defendant if the verdict had been adverse, but your impassioned judgment and mine would recognize that the doctor had made an error of judgment in the first instance and his pride and his personal equation restrained him from clearing the atmosphere between his patient's widow and his fellow-citizen.

Now, let us suppose that man had not died as the result of that fall but had gotten into an argument with an acquaintance in the course of which the acquaintance had made threatening gestures and had said, in the presence of a third person, that that man was not fit to live" and no more was seen of the threatened man until his body was picked up from the water when, in the course of an autopsy not a dislocated hip but a fractured skull was discovered; or let us suppose that no mark of external violence whatever was found and the doctor who made the autopsy certified the cause of death as "fracture of the skull" in the first hypothesis and strangulation without marks" in the second and, while recording "small contracted kidneys" or "large congested kidney" ignored these pathological conditions which would call for elimination as a potential natural cause for death before a criminal agency should be read into the record and do not supposed but understand

that we have a very necessary but a very uncomfortable quasi-presumption in law which is known as the "rule of exclusive opportunity" which would call for the arrest of the dead man's argumentative acquaintance as the last person seen with him in life, and suppose in the trial of this defendant for murder in the first degree, which is punishable by death, certain physical facts appeared in evidence, such as clumps of hair and relatively fresh blood on the string-piece of a dock near where the body was found, which would suggest a fall into the water occasioned by a uremic seizure and the head of a dying or dead man striking the string-piece and fracturing the skull, or that there appeared in evidence a physical fact such as froth issuing from the nose at two periods, immediately after the recovery of the body and within ten hours therafter which should indicate to the medical mind that there had been no traumatic interference with the breathing apparatus, and in the face of these conditions a medical man on the witness stand persists in assigning a criminal agency as the cause of that death, can we blame the bench and bar and the general public for entertaining a wholsome distrust of the medical expert who holds human life so cheap that he will let his conceit in a theory, or his pride, so influence his personal equation that he can restrain a natural impulse to arise in open court and cry out in the name of justice that a strong probability exists that he has made a mistake and that he is not willing to let his testimony jeopardize the life or liberty of the innocent.

The influence of the medical press can best be exercised, I believe, by fearlessly exposing these wretched abuses of the science of medicine as they appear in our courts from time to time and a working committee of your body which would keep in touch with important medico-legal cases as they arise and furnish your member publications with authoritative data upon which they could predicate editorial comment would go very far toward shaping the conduct of medical men and medical societies toward those members of the profession who are scandalizing our sacred calling, but we must bear in mind that however strong our denunciation may be it will be ineffectual with the deliberately dishonest and more direct means must be sought for their correction and control, and I know of no more efficient method than by interesting the legal press in encouraging and urging lawyers to acquire a working knowledge of the basic principles of medi

cine and to prepare the medical phase of a case with as much care as they do the purely lay issues of fact so that they may be equipped to approach the examination of medical witnesses intelligently; it is a source of very great regret to me that in our own State of New York the Court of Appeals has seen fit to eliminate from the course in law the subject of legal medicine so that a lawyer must approach a medicolegal case with no greater preparation than can be had in a few hurried conferences with a medical adviser and, while we have a number of medical men who have become lawyers within the past several years they are unavailable, either because the litigants cannot afford to employ additional counsel or because the lawyer in charge of the case is very naturally jealous of his prestige and hesitates to share the glory of his case with medical counsel.

At this point I would like to direct your attention to a very grave situation in regard to the employment and compensation of medical experts; we are all agreed that a laborer is worthy of his hire and that the medical expert has a duty to his family which precludes the use of his time and talents for the benefit of others without compensation and it will not be difficult for us to agree to that, while it frequently works a hardship, nothing can be done to help a plaintiff in moderate circumstances who is suing a wealthy corporation or individual in an action in negligence or a poor man in an action against an executor on the invalidity of a will, but in the criminal order, where a man is charged with a crime and is unable to employ medical assistance in the preparation of his defense he is in a most unfortunate plight if a medical question be involved; the prosecuting officer is empowered to employ such aid at the expense of the state and if that aid were competent and honest and judicial, as we would wish him to be, the cause of injustice would be fully served as between the people and the defendant, but if he be inclined to partisanship rather than the square deal, if he be a good vote-getter rather than a scientist, if he be a craft general who seeks to win a victory over his adversary then, indeed, is the defendant to be pitied and only through pity for the under-dog may he hope for acquittal at the hands of the jury unless there are those on that jury who can measure the expert for what he too frequently is a biased, dishonest witness worthy only of their contempt, and my anxiety for the defendant without means is not unfounded for I have heard a prosecutor's medical witness state

that he could and did determine the presence of human blood on a coat by measuring the red cells with a 1200 magnification and without the aid of any further and more accurate measuring apparatus despite the closeness in measurement which exists between the red cells of man and those of domestic animals, and in the same case another medical expert for the prosecution testified to the presence of human blood on a garment belonging to the defendant and upon cross-examination I found that his reagents for the biological tests had been made by a laboratory assistant and not under his own eye and he was actually determining the life of a man on trial for murder in the first degree on the sheerest hearsay that the reagents handed to his were biological test fluids, and on further cross-examination he was obliged to admit that he had made no effort to eliminate deer's blood and knew absolutely nothing about the relative response to microscopical and chemical and biological tests of deer's blood and human blood, and this in face of the fact that the defendant had stated immediately upon his arrest that the coat was his and had been worn while carrying a wounded deer and that the stain was the blood of a deer and despite the further fact, which I learned later, that the prosecuting officer had on three separate occasions reminded the doctor to determine this question of the presence of deer's blood on that coat and because the case against the defendant was strong or weak depending upon the medical testimony the court granted our motion to dismiss on the ground that the prosecution had failed to make out a case and did not ask us to put in a defense-but that you may know how near that defendant was to conviction and probable execution if the cross-examination had not revealed the incompetency and insufficiency of the medical evidence I want to tell you that one of the jurymen, a young man, American born and 35 years of age, in congratulating me upon the release of my client said he was lucky it did not go to the jury for he thought they would have convicted him, and when I asked him to tell me in the name of reason on what testimony he said: "Well, the man was dead, wasn't he? somebody killed him."

I am quite sure that my talk is not a revelation but a reminder and that your own experiences will make you quick to realize the danger which this problem presents and eager to do your best to limit if not eilminate it and that the medical press of this country will be a unit in a propaganda to readjust this relation between medicine

and law and that the time will soon come when we may pick up our morning paper confident that we will not be greeted by a slurring account of the dishonesty or incompetence of our fellows in the profession whose activities bring them into the courts and we may not be any longer forced to bow our heads in the humiliating consciousness that these men are of our order and have wrought the bar sinister into its shield.

397 Union Street.

THE POSSIBILITIES OF A NEW
SPECIALTY.*

B. F. ROLLER, B. S., M. D., New York. Such tremendous progress has been made by the medical profession in the last thirtyfive years that it would seem at first glance that the end must soon be reached. The whole field of medical science has apparently been covered, and in every branch of this noble profession such wonderful things are being daily accomplished that one could scarcely believe that another specialty could be found. It is in the fields where much interest and great activity have been manifested, however, that new specialties have always developed. The man who first invades a field is an explorer, a discoverer, an inventor, and not a specialist. Each field has proved to be so comprehensive that it embraces a number of specialties, and no man is big enough to cover expertly any field exhaustively today.

He must confine himself to the doing of a particular thing, and not what he does, but the end accomplished, determines the specialty. I mean that all specialties have certain things in common, or each, in other words, borrows from the other. All surgeons, for instance, have adopted in common the diagnostic methods and knowledge, the principles of asepsis and antisepsis, the fundamental facts of anesthesia, therapeutics, and ethics, but the specialist in surgery is the man who takes the facts that are universally useful in all the branches of surgery and with them does one thing more expertly than other surgeons do.

The slogan of the medical profession today is the prevention of disease. The world is astonished too at every quarterly report to learn the progress we have made along this line. Many dreaded diseases have almost disappeared from our records;

*Read before the 46th annual meeting of the American Medical Editors' Association, at New York City, October 18, 1915.

the death rate from many different causes has been enormously reduced; and the average age of life has been increased from 20 to 45. The work goes on progressing and apparently without abatement, though if we study the reports we will see that while we are progressing so wonderfully in many lines, in others we are not progressing at all, and in some we are rapidly going back. In fifteen years the death rate from all causes in New York City has been reduced from 20.57 to 13.4 per thousand, almost 35 per cent. In infant mortality the reduction from 181 per thousand births in 1902 to 95 in 1914, or 52.4 per cent, is equally striking.

These most acceptable figures, however, have been due to the recent discoveries which have enabled us to control the contagious and infectious diseases, the diarrheal diseases of children, to our advanced knowledge of surgery, and to sanitation and physical culture. Our hygienic measures have been a matter of public interest and adoption, and the cooperation of the people with our in some cases rather heroic but always unselfish methods has reflected increasing health and happiness in many ways. By the aid of the microscope and printer's ink the public has acquired an interest and pride in health, physical culture, and the prevention of disease, heretofore undreamed of. All this is most commendable and a source of much elation to both the people and the profession. In spite of the fact, however, that the slogan of the medical profession is the prevention of disease we are drifting into a most deplorable state of affairs, a condition in which a tremendous share of our most zealous efforts have already gone for naught, and one which can be seen to grow worse every day at a frightful pace.

Dr. S. S. Goldwater, New York Commissioner of Health, said in a brochure entitled "The Next Step in Preventive Medicine:" "The death rate from diseases of the heart thirty years." and kidneys has doubled in the last thirty years." Dr. Eugene Lyman Fisk in the promotion of a recently established life extension institute pointed out that "the diseases which are gradually being conquered, the diseases to which public health activities in the past have been directed are diseases of the self-limiting type, namely, those in which the human organism if possessed of reasonable resisting power, summons to its aid from its own But the diseases that are on the increase,' tissues and organs the antidote and cure. writes Dr. Fisk, "those of the degenerative class are not so characterized. Once their

[ocr errors]
« PreviousContinue »