DYING STATEMENTS IN CRIMINAL CASES

970

AMERICAN SURGEONS ON ACUTE APPENDICITIS IN a recent American discussion of appendicitis as a cause of death1 there was little advocacy of the delayed operation. It was, however, recognised by several of the speakers that by the time the surgeon saw the patient the disease might have reached a stage at which it was safer to trust to the localising power of the peritoneum rather than risk breaking down its protective barriers. Dr. Roy D. MOCLURE pointed out that the peritoneal spread of infection from the appendix varies ; in only a proportion of cases does it tend to localise. His statistics showed that the age of patients with abscesses was higher than the age of those with peritonitis, from which he concludes that the Ochsner form of treatment is more likely to be successful in those who are older. Dr. EDGAR P. HOGAN said that almost perfect results were reported by surgeons practising either the immediate or delayed operation. His explanation was that the experienced surgeon modifies his treatment according to circumstances : the advocate of delay would operate immediately when he thought it necessary, and the believer in immediate operation would leave the case in which delay was life-saving. Everyone agreed that the early case should have immediate operation; and also that the well-established abscess might be safely opened. It is the one seen at the stage of commencing peritoneal spread that needs most judgment, both as to the " when " and the " how " of operation. There was point in Dr. HUBERT ROYSTER’S contribution to the discussion: " I have said repeatedly that I would take my chances, and so would you, with a mediocre surgeon if I had an unruptured appendix, rather than have the most expert surgeon at the eleventh hour." Dr. HOGAN quoted M. RICHARDSON’S opinion, given in 1894, that he occasionally saw cases too late for the early operation and too early for a safe late operation. It is obvious from the context that RICHARDSON applied his principle with care, and by no means always held his hand in cases first Nevertheseen on the third, fourth, or fifth day. less the principle stands and HOGAN thinks that the fact that it was at one time largely disregarded accounts in part for the high mortality from appendicitis in the United States. He quoted Sir JAMES BERRY’S comparison of the fate of King EDWARD VII and of President EBERT of Germany.2In 1902 King EDWARD had a delayed operation for appendix abscess. He was first seen by a surgeon on the fifth day of illness, and the operation-a simple drainage of the abscess-took. place on the eleventh day. He lived. President EBERT, in 1925, was seen by a surgeon about 21 hours after the onset of his attack and the operation was done three hours later. The appendix was removed by free incision into the peritoneal cavity, and he died four days later. The difficulty is, of course, to be certain in which cases a localised abscess will form. 1 Ann. Surg. 1937, 105, 800. 2 Lancet, 1932, 1, 1027.

American surgeons are much concerned about the continued high mortality. Dr. R. S. Hrr/r, said he felt safe in saying that the progress of American surgery had been satisfactory in every respect other than the reduction of the death-rate from appendicitis. A fair summary of the con. clusions of the discussion seems to be that early operation, within a few hours of the onset of the illness, is the surest means of decreasing the deaths ; but that when there has been a delay the services of an expert surgeon are required, both to determine the safe time to operate, and to perform a safe operation. The diagnosis, as Dr. HOGAN put it, should not wait for the stage of subjective symptoms in the right iliac fossa. It should be made before there is enough local infection to produce local symptoms. At the stage of generalised pain there is already, as a rule, localised tenderness. Dr. J. T. MOORE remarked that there were a few principles that he tried to instil into the minds of the coming surgeons of his State : to avoid purgatives till the diagnosis was made ; to operate immediately after making the diagnosis, provided they knew how to operate properly ; and to get the appendix out without ever letting the ileum come into contact with anything septic. He attributed the high mortality in his part of the country to the performance of so many operations by general practitioners. The discussion revealed a con. sensus of opinion in favour of the McBurney incision, most of the speakers insisting that in acute appendicitis it is pretty well criminal to use the right rectus incision. An incision so small that it is impossible to bring anything but the appendix through it was Dr. MOORE’S choice. He tries to see nothing but the appendix and the caecum and, to ensure this, he makes the incision far out. The right rectus incision he designated an exploratory incision and not an incision for

appendicectomy. On the question of drainage, Dr. EDWARD CAFRITZof Washington is the latest to argue against draining the peritoneal cavity in most cases of appendicular peritonitis. He excepts those in which the appendix cannot be removed, or in which a large mass of necrotic material is left behind; and, of course, he drains walled-off abscesses. In all other circumstances he believes that the drainage is so localised as to be useless, and that it favours both post-operative mechanical ileus and post-operative hernia.

DYING STATEMENTS IN CRIMINAL CASES THE City of London coroner last week approved the action of a member of the medical staff of one of the big London hospitals who had called in the police to take a dying statement " from a woman patient. There had been a recent miscarriage. A medical practitioner whom the deceased had consulted stated at the inquest that she had asked him to terminate her pregnancy; this he had declined to do in terms which the coroner evidently "

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J. Amer. med. Ass.

1937, 108, 1317.

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diplomatic.the dying statement may contain the full story In one leading case There was reason to think that the dead woman. of an illegal operation. afterwards had recourse to someone less scrupulous. (R. v. Perry, 1909) this conversation occurred Her husband said that, after coming out of a period between the dying woman and her sister. " Oh ! of delirium, she used the words " do not give Blank: Maggie," said the sister, " what did you have that away," mentioning someone by name. Post- woman for ? I don’t like her." " Oh ! Gert," mortem examination showed nephritis, itself a replied the dying woman, " I shall go, but keep possible cause of miscarriage. A verdict of deaththis a secret." She then gave a detailed account

regarded

as

admirably

correct and

of what the abortionist had done to her ; this was admitted at the trial and conviction followed. The case illustrated what is the main point in dying statements. Did " I shall go mean " I shall die very soon " ? The trial judge thought it did, and the Court of Criminal Appeal did not interfere. There must be evidence of the consciousness that death is coming, in Lord ALVERSTONE’S words, " within a very very short distance of time," though not perhaps the same day. What the doctor thinks of the prospect of recovery is immaterial. It is what the patient thinks that matters. In R. v. Cleary (1862) where a man had been shot through the body but said he did not think he would die, the court refused to presume that he must necessarily feel that, with such a wound, he could not recover. In R. v. Morgan (1875) Mr. Justice DENMAN discountenanced the idea that, by crediting the deceased with ordinary intelligence, one could infer that he must have been conscious of impending death. There are, however, cases where the grave nature of the wounds has made it easy to convince a court that the dying person had the necessary " settled, hopeless expectation of immediate death."

from natural causes was returned. The duty of the doctor in respect of dying statements is clearly explained in medico-legal text-books. He should tell the patient as kindly as possible that she is dying and should put the simple question " do you wish to make any statement ? " It is permissible to point out the importance and advisability of making a statement and to explain the use which may be made of it in defending the innocent or punishing the guilty. To give the opportunity of making the statement (by asking the question already mentioned) is the main duty; the urging of the patient to do so is, so to speak, secondary and discretionary. If it is to call in the the authorities, possible police responsibility is naturally transferred. The doctor’s task is to note carefully the condition of the patient’s mind. If he himself is taking the statement, he should write it down at the first opportunity, and in the actual words used by the dying person as far as possible. He should avoid putting leading questions and, inasmuch as clarity of mind may not be conspicuous at a moment of considerable agitation, he should bear in mind that the law looks a little suspiciously at any effort to secure a death-bed identification of an accused person by confronting the latter with the

account

AT the request of the Royal Australasian College of Surgeons, the primary examination for the fellowship of the Royal College of Surgeons of England will be held in Melbourne, Sydney, and Dunedin during

patient.

of the admissibility of a dying statement is for the court to decide. The doctor who obtains the statement leaves that question November and December. A similar examination to the judge. The admission of such evidence is will also be held in Bombay early in January and in a remarkable exception to the general principle Cairo at the end of January. The Cairo examination of criminal law that hearsay is inadmissible and is the first of its kind in Egypt, and the invitation that evidence can be given only on oath in open comes from the dean of the medical faculty of the The Egyptian University. Mr. C. P. G. Wakeley, a court where cross-examination can follow. law excuses the exception by holding that, where member of the council of the Royal College of Surgeons and senior surgeon to King’s College Hospital, will persons have a settled, hopeless expectation of act as the examiner in anatomy at each of these immediate death, they will not (in language now examinations, while Prof. A. St. George Huggett, of possibly regarded as old-fashioned) go into the St. Mary’s Hospital medical school, will examine in presence of their Maker with a lie upon their lips. physiology. There are 96 candidates in Australasia, " A situation so solemn and so awful," said Chief 85 in India, and 22 in Egypt, and at each centre the Baron EYRE in R. v. Woodcock (1789), "is con-examiners will act with assessors appointed locally sidered by the law as creating an obligation equal by the council of the College. The director of to that which is imposed by a positive oath adminis-examinations, Mr. Horace H. Rew, will be responsible tered in a court of justice." A child of four, befor the conduct of the examinations in India and it noted, cannot make a valid dying statementEgypt. because it is not old enough to know of the alterDr. L. Haden Guest was successful last week when 3 contested the North Islington division in the native prospects of Heaven and Hell (R. v. Pike,he 1 labour interest. He is a seasoned Parliamentarian 1829) ; but the statement of a boy of ten has been and Southwark (North) in 1923 when he represented admitted (R. v. Perkins, 1840). One other limitaThe

question

I

became

to

the

Parliamentary private secretary , noteworthy. Dying statements are admis- .Minister of Health. There was nothing specifically sible only on charges of murder or manslaughter, medical in his election address this time but at his not in those of perjury, robbery, or rape, or anymeetings he laid stress on the importance of thing other than homicide. Thus they are notiimproved nutrition, basing his argument on Sir admitted in prosecutions for criminal abortion,John J Orr’s facts and figures, especially as to the L of milk. though, if the charge is murder or manslaughter,use tion is

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