Conflicts of Medical Evidence.

1559 t in Lyons four deaths occurred in ten years, all from direct transfer of a small portion of the original tumour house t and no deaths from any other cause. from one person to another, and so far it is not necessary cancer, In other cases it is difficult to know whether to look upon to invoke the aid of a cancer microbe. t disease as due to contagion or to locality. For instance, There is, however, another group of cases which are only the a medical man married a lady who died from mammary and a the that certain on localities are supposition explicable i cancer ; he later had cancer of the stomach and liver especially prone to cause cancer in the inhabitants. Mere uterine a his second wife had cancer of both breasts. Mr. R. coincidence is inadequate to explain these cases, for theyand There is a little village in Normandy (CLEMENT LUCAS in 1883 removed a rodent ulcer from the are too numerous. i of a man who later had a return of the disease ; named Saint Sylvestre-de-Cormeilles which contains only forehead i ARNAUDET has shown that cancer is in 1884 the man’s wife had scirrhus of the breast, and in some 400 inhabitants. extremely common there. The deaths from cancer in Paris 1887 a partner living in the same house had epithelioma of form 4’16 per cent. of the deaths from all causes, but in this tthe tongue. These cases could be greatly multiplied in number, but Tillage the percentage is 14’ 88, or more than three times s An attempt has been made to invalidate the sufficient have been related to show that there is at least a as great. force of this case by showing that if we take the whole of primâ-facie case for the theory that cancer is contagious, Normandy the death-rate from malignant disease is noand also that it is associated with certain localities and with ceitain water-supplies. 1 greater than in Paris, but, of course, this is no answer. perhaps The In an extensive district like Normandy the conditions are only possible explanation of all these facts, if they are not mere coincidences, is that cancer is microbic in so varied that statistics derived from this origin large region In That we have not yet found the organism and that we cannot cannot invalidate those derived from a smaller area. England, also, it has been shown that in certain areascultivate it on artificial media cannot be advanced as valid

malignant disease is much above the arguments against the microbic theory, for, as Sir JAMES ngham and Midland Counties PAGET pointed out, the same arguments were at one time average. Branch of the British Medical Association appointed aapplied to the theory of the microbic origin of tubercle. The research was leprosy, and tetanus. Whether the microbic theory be true or committee to investigate this question. limited to the counties of Warwick, Stafford, Salop, and false time will show, but there is sufficient probability of its Worcester, and it was found that in certain parishes truth to make it our duty to be very careful of spreading the the mortality from cancer was far above, while in disease. There was a time when a surgeon would go straight other parishes it was below, the average for the whole from a case of cellulitis to perform an amputation ; and the kingdom. The facts are undoubted, but their explanation results we know. Applying our knowledge of sepsis to the death-rate from

In 1898 the B:rm

Still more striking, however, are the facts which go to show that in certain small groups of houses, or even in individual houses, an excessive number of deaths from cancer occurs. A very noteworthy case is recorded by Dr. ALEXANDER SCOTT. Three men, all unrelated, succeeded one another as night-watchmen, each one occupying the same bedroom as his predecessor ; they all died from cancer Dr. CHAPMAN has put on record the within four years. fact that three successive tenants of a house all died from malignant disease of the rectum. Other striking cases have been recorded by Mr. T. LAW WEBB and by Mr. is another matter.

HAVILAND. In one case there were two houses under one roof with a common water-supply and a common drainage system. In one of these houses 30 years ago a man died from cancer of the rectum. The house was next occupied by a man and his wife ; the man died two years later from carcinoma of the stomach, and his widow, who continued to live in the house, died ten years later from cancer of the rectum. Before the death of this patient a Mrs. R. who lived in the adjoining house had cancer of the breast and at her death the house was occupied by three maiden ladies ; one of them died from cancer of the uterus and another died with all the signs of cancer of the stomach. Mr. D’ARCY POWER relates the following case. A Miss B. lived as housekeeper in a house in a suburb of London for 13 years and died from cancer of the stomach in 1884. Miss T., who had lived in the house 20 years, took Miss B.’s place and occupied her bedroom and died from cancer of the liver in 1885. Mrs. J., who had lived in the house eight years, took her place and occupied her bedroom and died from cancer of the breast and uterus in 1893. Dr. FA]BRE relates that in a

carcinoma we cannot fail to see that a surgeon should not incise a malignant growth and then with the same knife excise it, for there cannot but be a possibility of infecting the

healthy tissue. All discharges from cancerous growths should be looked upon as possibly liable to cause an extension of the disease ; the stools of patients with cancer of the bowel should be considered as possibly capable of spreading infection ; and the repeated, or even the single, occurrence of malignant disease in a house should call for an examination of its drainage and watersupply quite as much as if the patients had suffered from enteric fever.

Conflicts of Medical Evidence. opening of the of of Section the Medicine in Surgical Royal Academy Ireland Mr. L. H. ORMSBY, President of the Royal College of Surgeons in Ireland, discussed the causes of the conflicts of medical evidence frequently arising in courts of justice.1 By a coincidence a few days later in the King’s IN his Presidential Address read at the

Bench Division Mr. Justice LAWRANCE, giving judgment in the case of WATERS v. the Brighton Gas Company, (an account of which will be found at p. 1570 of our present issue) refused to allow the successful party the cos’sof the medical witnesses, saying apparently, "Iwill give nothing to the medical witnesses," this being done presumably to mark an opinion of his lordship either that someone was to blame for laying conflicting medical evidence before him or that the medical men were themselves tc) .

1

THE

LANCET, Nov. 29th. 1902,

p. 1491.

1560 and that patient cannot be taken to pieces for demonstration of his plight to a jury. It has been suggested that medical men should sit as assessors in lay tribunals to which medical questions are submitted, and the medical referees appointed under the

blame in that their views did not coincide. That medical men should publicly differ among themselves is a matter of regret to no one more than to members of the medical profession, but whether such differences of opinion should impart any blame to them, or whether more or less public censure should be levelled at them without inquiry or consideration of the causes of difference is another matter. The

conflicting

nature of

law is

frequent subject

courts of

expert evidence given in of

and private comment, but it is difficult to see how conflicts of expert evidence can cease to exist so long as questions which must remain essentially matters of opinion only are discussed in courts of law with issues of momentous importance to the parties dependent on them. Expert evidence is that of those whose special experience qualifies them to give it upon questions as to which evidence of fact cannot be a

given

inquiry

is not

one

the facts

The contradictions of of which can be pro-;ed as such. in occur all of cases in which it evidence classes expert has to be given. They are to be observed when engineers

Compensation

experiment

in this direction.

Acts may be regarded as an Such a system would have its

and also, perhaps, its drawbacks. We observe ORMSBY, in the address to which we have called

advantages that Mr.

public

because the matter under

Workmen’s

sent to

following resolution by the Council Royal College of Surgeons in Ireland was recently each of the judges of the Supreme Court of Judica-

ture in

Ireland, but that,

attention, of the

stated that the

been received

’,

so

far

as

he

knew,

no answer

had

:-

That the President and Council of the Royal College of Surgeons in Ireland, having regard to the necessarily technical nature of the medical evidence, are of opinion that in cases of actions for damages for personal injuries, the court itself should obtain the assistance of a medical expert other than those employed by the parties to the suit.

We should much like to hear the view of the Irish endeavour to point out and to estimate the existence and judges on the matter. As for Mr. Justice LAWRANCE’s value of novelties in an invention, or where handwriting attitude towards the medical witnesses in WATERS v. the experts seek to identify or to distinguish the penmanship Brighton Gas Company, though to do so savours of of

forger,

well jury in

where medical

called damages for

lordship that every year assessing litigants owing to their pounds In and in all such cases, many others, counsel advising appeals to higher courts upon points which personal injuries. the contradictions are made the subject of reproach levelled are ultimately decided against them. Again, the opinions at the professions of those who have honestly differed in of Lords Justices of Appeal are often over-ruled by the their opinions, the witnesses are liable to every kind of House of Lords at the expense of suitors to whom these suggestion of corruption and wilful error being made against differences of opinion among distinguished legal experts them by adverse and irresponsible advocates, and judges, involve the loss of large sums of money. The positions juries, and arbitrators, not themselves experts, have to of the two professions are not precisely similar but arrive at their conclusions in spite of the contradictions as both serve to illustrate our contention that there aie best they may. It is at the same time clear that if opinions matters upon which scientific men, whether their science must be given upon matters not ascertainable as facts, such be medicine or law, may honestly differ, and that their opinions are not likely to coincide. It is only a matter of differences are not to be treated as if they involved garbling regret that evidence of this kind should so often be of facts. We are not aware that when questions have been required from medical men in circumstances which make it taken to the House of Lords costs in respect of counsel’s To go into the fees are disallowed to mark their lordships’ views upon the difficult for them to refuse to give it. witness box subjects the medical witness in many cases to differences of legal opinion that have been ventilated before a disagreeable experience ; he is liable to have very serious them. Our contention is that one learned and honourable imputations of corruption and error made against him and profession deserves courteous treatment at the hands of against his profession, the members of which of all others another. are desirous of ascertaining and elucidating the truth. The differences in opinions expressed by medical men may arise in assigning symptoms of illness or injury to a given cause or dissociating them from it, or in estimating the probable future duration of these symptoms or of others Ne quid nimis." ikely to ensue, and in a variety of other ways, but there is a particular hardship which affects members THE ROYAL ARMY MEDICAL CORPS MEMORIAL The engineer and the of the medical profession alone. FUND. a

to aid

the

as

as

a

men

claim for

are

tu quoque,

we

thousands of

must

remind are

his

lost to

Annotations. "

expert can

in

handwriting, whom we pieces the machine, document, and examine

take to

have used or

as

examples,

the words and letters

component parts in the light of their knowledge and experience. The medical of the

has in many cases to of invisible conditions by man

judge

the

of the presence

symptoms

not

patent

or

absence

to the eye

described by a deeply-interested witness-the party himself. He has to risk his professional reputation upon opinions that he can only arrive at after first forming an estimate as to the veracity of the patient submitted to him, but

SOME months before the termination of hostilities in South Africa it was decided that a memorial should be erected to all ranks of the Royal Army Medical Corps who fell in the South African campaign. With this object, after consultation with the Director-General of the Army Medical Service, a provisional committee was formed in South Africa to consider the question generally, and the recommendations of this committee were forwarded by the Director-General to the. principal medical officers of all districts with a request that they’would arrange for the collection of subscriptions which Messrs. Holt and Co. had