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The examination of a patient for medicolegal purposes
THE EXAMINATION OF A PATIENT FOR MEDICOLEGAL PURPOSES FRANK L. FLACK, M.D., Chief
Surgeon,
SincIair
TULSA,
T
Prairie
F.A.C.S.
Companies
OKLAHOMA
HE main object of a11 medica endeavor is to restore people who are sick or injured to as near a normal condition of health and abihty to carry on their gainfu1 occupations as is possibIe. This is of great importance in the economic phase of medica treatment, particuIarIy in persona1 injury cases. A large percentage of peopIe are either interested in or empIoyed by some branch of industry. AI1 industries have both physica and menta1 hazards. Accidents and disabiIities, and cIaimed accidents and disabiIities, arise in great numbers daiIy. Vast numbers of cases are continuaIIy coming to various courts and commissions for the adjustment of cIaims and the determination of Ioss of earning power, but there is great and intoIerabIe variance in these ciaims. Unfortunate and unreasonabIe disputes arise as to the diagnoses, causes of conditions or cIaimed conditions, and these produce heated arguments before tribunaIs of adjustment and arbitration. Many patients and cIaimants are poor. As can be readily seen, this introduces an important factor invoIving the question of money. The mora1 sense and administration of justice and fairness is aIways, by a11 odds, best for a11 parties concerned. It is a sine qua non that the best and most expert treatment that can be given an injured patient is for the greatest amount of good for a11 who are interested in the case. It certainIy is not fair for a cIaimant to continue to draw compensation at the rate of $18.00 per week under the impression that he is not abIe to work when as a matter of fact he is abIe to carry on his usua1 occupation and earn $35.00 per week-which he and his dependents need. This unfairIy produces chronic invaIids and unjustIy deprives a wage earner of the opportunity
to accompIish the things he reasonabIy shouId. To induce protracted disabiIities is to produce chronic invaIids and neurotics. On the other hand, it is not fair for a cIaimant, suffering from a disabiIity, the resuIt of an accident, and who is not abIe to carry on his usua1 work, to be denied monetary compensation which is rightfuIIy due him. The theory of compensation for injury is not new. In the OId Testament it is stated, “And if men strive together, and one smite another with a stone, or with his fist, and he die not, but keepeth his bed: “If he rise again, and waIk abroad upon his staff, then shaI1 he that smote him be quit: “OnIy he shaI1 pay for the Ioss of his time, and shaI1 cause him to be thoroughIy (Exodus 21:18-19) heaIed.” It shouId not be Ieft to chance what particuIar medica man shouId treat certain cases. IndustriaI surgery is a specia1 branch and shouId be delegated to those particuIarIy skiIIed in this type of work. A doctor chosmg to do industria1 work shouId educate himseIf aIong these Iines. He shouId have a thorough understanding of compensation Iaws, and shouId cooperate with a11 interested parties to the fuIIest and fairest extent. His duty is to report promptIy to them his findings on examination and his honest opinion of the case. The best work is secured today under conditions whereby medica men are unhampered by the continuous disturbance of economic competition and the frequentty necessary struggIe for existence. It is best for the empIoyee and the empIoyer for an experienced and capabIe surgeon to be paid $100.00 to repair an injured part of the body and secure a resuIt with a disabiIity amounting to $500.00
506
A mrrican
Journal
of Surgery
Flack-Medicolegal
than to pay a doctor who is not skiIied in the handiing of such cases $50.00 and secure a result where the disabiiity wiii be $2,000.00.
The advancement of science and the increase of medicai abiiity has reached such a stage that there shouid no Ionger be a wide divergence of opinion as to the extent and causes of disabiiities. Certainiy, if competent doctors for both sides meet and consult and examine the case, one wiii not estimate a disabiiity at 75 per cent while the other estimates the same disabiiity at 15 per cent. I suggest that competent physicians for both sides examine the case in conference, and without predjudice, before the case is presented to any tribunai. If such procedures were foiIowed, the greatest percentage of cases wouid be settied without triais or contests. When competent doctors examine patients in private practice, the patients are carefuiiy studied, the various angies are impartiaiiy discussed, the questions of diagnosis and treatment are considered over a period of time, particuiarIy if there are any points of difference. After these matters have been considered, after the physicians have read in standard works concerning the various questions, and after carefuI thought has been given about the best interests of the sick person it is not often that there is any great difference of opinion. The reason for this is that the chief interest is in the diagnosis and treatment and is not influenced by any court procedure nor by anything except scientific medicine and the weifare of the patient. Certainiy, after fair consideration, this shouid be the case in arriving at the diagnosis and disabiiity in any injury or alIeged injury, The primary purpose of a medica examination is to determine the facts as based upon a study of the case and shouid not be influenced by any other thought. Frequentiy the interests of an injured person are better served by competent and fair consultations. Such a procedure as this wiii go a iong way in increasing the weight and credence piaced
Examination
DecsMeeR, 1938
upon the testimony of doctors as given in courts. The jury, judges and commissioners arrive at a conciusion concerning the merits of a case by considering factors such as pain, Ioss of function, deformities, and ioss of earning capacity as we11 as factors of IegaI merit. It is necessary, therefore, to present the actua1 and the compIete examination findings, without exaggeration and without underestimating the disabiiities. Of course, there is only one way to prepare a medica case for iegai determination and that is to make an inteiIigent and sufficient examination. This in&ides not oniy a physicai but aiso a mentai study. To make such a survey successfuiIy it is necessary, in the first place, to obtain the confidence of the patient by fair means and by a manifestation of interest. This study shouid be complete and thorough, and shouid estimate, with fairness, the vaiue and weight to be given on the ciaims. It may safeiy be stated that the most carefui and skiifui examination of the patient is for the best interest of the pIaintiff and defendant aIike. A compiete diagnostic survey is necessary in practicaiIy a11 cases which may resuIt in a triai before some court of record. It is not suflicient to stop wit.h an examination which discIoses absent knee jerks, a Rhomberg, and iack of co6rdination. CertainIy, in such a case, a Wassermann test shouid be made, the pupiIIary reflexes shouid be determined, and a compiete neuroiogic examination carried out. If a patient has suffered an injury and compiains of paresthesia of the iower extremities, ataxia, aitered vibratory and position sense, and a parapiegia, and evidence of injury to the pyramidai tracts, the examination should not stop at this piace. A skilfui physician will usuaIiy fmd, on making a carefui biood examination, that pernicious anemia is the cause of the disabihty and that it is not due to iifting on a joint of pipe. Extreme nervousness and trembiing and genera1 debility may be
NEW SERIES VOI_ XLII,
No. 3
Flack-MedicoIegal
found, after a carefuI examination, to be due to muItiple scIerosis. These are onIy a few exampIes showing the necessity for making a compIete examination in any case that is of any consequence. Such an examination may prevent a doctor from being humiliated and discredited in court, when cross examined by a shrewd Iawyer, we11 informed on the particuIar case. A speaker on any subject must keep the kind and cIass of his audience in mind. Different cIasses of audiences demand different expIanations. When any matter is presented, one must consider the kind of peopIe to whom it is presented in order that an expIanation which can be understood wiI1 be made. Otherwise the issue is wasted, time is lost, and the case is not understood. Juries are not composed of doctors, nor of men familiar with technicai medica terms. Judges, commissioners and Iawyers are not doctors and hence are not presumed to be famiIiar with comphcated medica language. In preparing a case to present the facts for study to others than doctors, understandabIe terms and words must be used. Jurors know what one is taIking about when the words, “wrist” and “ ankIe,” are used, but ordinariIy they do not know what is being discussed when such terms as “trapezium,” “scaphoid,” “astragaIus, ” or “OS caIcis” are used. The expIanation of the word, and significance of the term “fracture” must be made cIear to laymen. Fractures of the transverse processes of the spina vertebrae are frequent and they usuaIIy hea by fibrous union and do not show bony union in the x-ray pictures. Such patients practicaIIy always recover and are abIe to carry on their work and have no disability. These are facts estabIished by many hundreds of cases. CertainIy it is not wise to eIaborate about the patient with a broken back and make a11 the impIications that are carried with such statements without some fair expIanation of the particuIar case in point so that it may be reasonabIy understood. The anatomic expIanation that the spinai cord ends at the second Iumbar
Examination
American
Journal
ol Surgery
5T-
vertebra wiI1 throw some Iight on the frequent cIaim that a sIight compression fracture of the fourth or fifth Iumbar vertebra is pressing on the spina cord. The statement that a patient has a broken back, and the aIIusion that he has an injured spina cord must be carefuIIy expIained to the attorney wit.h reference to its significance as to disabiIity. One of the most frequent types of cIaims is for injury of and disabiIity to the back. A Iist of the causes of backache wouId in&de practicaIIy every disease, injury and congenita1 deformity that exists. Due to the frequency of these cIaims, there are a few commonIy accepted points which have been proved by experience and which are based upon anatomic findings with which an attorney shouId be famiIiar. A history of a gradua1 onset of pain which becomes progressiveIy worse is most frequently due to an arthritis or to some disease. The patient shouId be required definiteIy to Iocate the pain and this Iocation shouId be noted. At subsequent examinations it shouId be determined if this Location has changed. Pain in the back due to a genuine injury or a really definite cause does not switch and jump around a11 over the back. It is we11 known that a patient who has a pain in his back which is the resuIt of a sprain of the muscIes or Iigaments has more troubIe and more disabiIity in the morning, after a night’s than he does with moderate rest, exercise. After it has been explained to a Iayman, he is abIe to note some of the physica characteristics of the patient: his buiId, the presence or absence of abnorma1 curves in the spine, whether or not there is tiIting of the pelvis, and other representative findings. AIways examine for the presence of muscle spasm or atrophy in the region of the area compIained of. The motions of the spine are easiIy obtained and can be seen by any Iayman. The patient should be requested to bend to the right and to the Ieft, to bend forward and to bend backward. The Iocation of the pain during these move-
508
A mrrican
Journal
of Surgery
FIack-MedicoIegaI
ments shouId be determined. Be particuIar to ask if the pain is increased or relieved by any one motion. In genuine back pain due to injury, the pain is increased by some motions and reIieved by others. In a rea1 case of injury, the patient does not compIain of severe pain when a11 the various motions of the back are performed. In flexing the back, tensIon is pIaced on certain muscIes which may be painfu1 on account of an injury, but when extension is performed, these muscIes are reIaxed and the pain is reIieved. The significance of vaIuabIe Iaboratory tests wiI1 be Iost unIess a carefu1 and cIear expIanation of their meaning is made to Iaymen. One of the most important points to be brought out during the examination is the history and description of any previous iIIness. Occupation is a matter to be considered because certain occupations pIace a definite strain on certain muscIes and this strain is usuaIIy a continuous one. An effort shouId aIso be made to estimate and determine the type and characteristics of the individua1. Different types of peopIe react differentIy to the same amount of pain. It is necessary to estimate whether the patient is excitabIe or nervous, or is of a phIegmatic disposition. In examining the extremities, measurements can be taken with the tape measure with the expenditure of very IittIe time. Such measurements are very impressive to laymen in determining definite conditions. The subject of fractures of the skuI1 frequentIy presents itseIf. It cannot be too thoroughly emphasized to Iaymen that the skuI1 fracture is not the thing of importance, but that it is the damage to the contents within the skuI1 that is of importance. Always make the more common neuroIogic tests, which require not ski11 so much as time. Determine the condition of the deep tendon reflexes such as the knee jerks, ankIe jerks, biceps and triceps reflexes. Make the usua1 tests for sensory disturbances, such as the distinction between sharp and dull, the abiIity to deter-
Examination
DECEMBER, 1938
mine pain and touch, the vibratory sense and the sense of localization. The significance of the various common findings can, with inteIIigence, be expIained to someone not versed in medicine in such a way that they wiI1 be understood. If anything of an ahnorma nature is found, a carefu1 and more exhaustive examination of the nervous system shouId, of course, be made. Injuries to the skuI1 and spine have so frequentIy been considered by the layman as serious, dangerous and Iasting disabilities and it has been so repeatedIy emphasized that a person with a broken back wiI1 never be abIe to do fuI1 work again that a fair and honest expIanation of the terms and meaning of the particuIar findings in the case shouId be made. EspeciaIIy in medicoIega1 cases is it wise to make repeated examinations and observe the patient over a period of time. We11 do I remember taking care of a man who had compression fractures of the third and fourth Iumbar vertebrae-and they were compressed to an extreme degree. No neuroIogic changes from the norma were present, but definite muscIe spasm was found. When I dismissed him from my care about nine or ten weeks folIowing the injury, I estimated, in good faith, his partia1 permanent disabiIity at 65 per cent. About two years later, this same man, with the same compression fractures, came to my offIce with the statement that he had no disabiIity, that he had no pain, that he feIt himseIf fit in every way to resume any kind of manua1 Iabor. A carefu1 physica examination reveaIed no objective signs of disabiIity, and I feIt that there was no reason why he couId not carry on the same work as before the injury. The mora1 of this experience is that in preparing cases for IegaI presentation, we must impress the fact upon Iaymen that time is a great heaIer and that repeated examinations and observations are frequently necessary for the proper evaluation of the disabiIity in such cases. It must be expIained that x-rays do not determine disabiIity nor Iack of disability.
NEW
SERIES VOL. XLII, No.
3
Flack-MedicoIegaI
X-ray pictures of a fracture that looks terrible may be x-ray pictures of an extremity that has excellent function. Again, of course, the reverse may hold: an x-ray picture may look good, but function of the extremity may be impaired. To determine the presence of an ulnar nerve injury, observe whether the patient can abduct or adduct his fingers. Abduction and adduction are not possible where the ulnar nerve has been injured, for the reason that the ulnar nerve supplies the muscles which control these motions. Similar tests, based on anatomy and sound reasoningtests which are obvious-may be used in different types of cases. Legal cases, involving medical questions, are prepared by doctors and lawyers together and the conditions must be explained in such a way that the reasons are evident to lay minds. Attorneys must have familiarity with the case in order that they may present the matter in an intelligent manner to laymen in order to assist them in reaching logical and reasonable conclusions. Most objective findings are overlooked because not enough time is taken in determining the common conditions and examining for the findings which may be obvious. One should always present all of the facts to the lawyer consulting you, giving him both sides of the case. This is the only fair way and the method necessary to prevent many court surprises and difficult situations. It is advisable, wherever possible, to have the attorney present when examinations are made. Observation is one of the best ways to become familiar with a case, and in this way the attorney has the facts that are important indelibIy impressed upon his mind in such a fashion that he will remember them and they will have a meaning. The question of inguinal hernia due to an injury frequently arises. Of course, we know that an inguina1 hernia, if it is ever traumatic, is extremely rare, but when such a case presents itseif, a complete history is essentia1. It should be considered whether or not the cause could reasonably have any connection with the condition cIaimed.
Examination
American
Journal
of Surgery
309
Other important anatomic and medical ideas and reasons should be carefully discussed with the attorney in connection with such a case. No matter what type of disability or injury is to be tried before a court of record, the points shouId be explained to the attorney in language which he wil1 understand. Reasons for such explanations are given so that the attorney can, in turn, discuss the matter intelligently with the person or persons passing upon the merits of the case. The attorney must understand that certain diseases produce findings that are visible to an intelligent observer. A patient with a definite sciatica walks with a list to one side, and assumes a quiet position without continuous twisting and squirming and jumping around in his chair. In the preparation of a case for legal presentation, if the facts are carefully obtained, without prejudice and presented in terms that can be understood by lawyers, courts and juries, the most important steps in securing an equitable adjustment will have been obtained. It again must be repeated that time and patience are necessary for the proper and fair preparation and presentation of such technical matters to non-medical men. The record of injury, its time, the dates of treatment, the various complaints, the progress notes and the fmdings must all be kept in writing because the doctor will almost certainly be called upon to testify concerning these facts. A doctor handling a large number of cases will not make a proper impression if he relies upon his memory as to a large number of complaints, details and dates. A great part of the reward in the practice of medicine is the pleasure derived from studying and examining cases and discussing them with competent colleagues. This is one of the ways in which we keep up with the advances in medicine. It is best for the patient, and certainly is the most efficient way to prepare a case which is to come up before some tribunal for a hearing on the facts and an estimation of the disabiIity.
Surgeon,
SincIair
TULSA,
T
Prairie
F.A.C.S.
Companies
OKLAHOMA
HE main object of a11 medica endeavor is to restore people who are sick or injured to as near a normal condition of health and abihty to carry on their gainfu1 occupations as is possibIe. This is of great importance in the economic phase of medica treatment, particuIarIy in persona1 injury cases. A large percentage of peopIe are either interested in or empIoyed by some branch of industry. AI1 industries have both physica and menta1 hazards. Accidents and disabiIities, and cIaimed accidents and disabiIities, arise in great numbers daiIy. Vast numbers of cases are continuaIIy coming to various courts and commissions for the adjustment of cIaims and the determination of Ioss of earning power, but there is great and intoIerabIe variance in these ciaims. Unfortunate and unreasonabIe disputes arise as to the diagnoses, causes of conditions or cIaimed conditions, and these produce heated arguments before tribunaIs of adjustment and arbitration. Many patients and cIaimants are poor. As can be readily seen, this introduces an important factor invoIving the question of money. The mora1 sense and administration of justice and fairness is aIways, by a11 odds, best for a11 parties concerned. It is a sine qua non that the best and most expert treatment that can be given an injured patient is for the greatest amount of good for a11 who are interested in the case. It certainIy is not fair for a cIaimant to continue to draw compensation at the rate of $18.00 per week under the impression that he is not abIe to work when as a matter of fact he is abIe to carry on his usua1 occupation and earn $35.00 per week-which he and his dependents need. This unfairIy produces chronic invaIids and unjustIy deprives a wage earner of the opportunity
to accompIish the things he reasonabIy shouId. To induce protracted disabiIities is to produce chronic invaIids and neurotics. On the other hand, it is not fair for a cIaimant, suffering from a disabiIity, the resuIt of an accident, and who is not abIe to carry on his usua1 work, to be denied monetary compensation which is rightfuIIy due him. The theory of compensation for injury is not new. In the OId Testament it is stated, “And if men strive together, and one smite another with a stone, or with his fist, and he die not, but keepeth his bed: “If he rise again, and waIk abroad upon his staff, then shaI1 he that smote him be quit: “OnIy he shaI1 pay for the Ioss of his time, and shaI1 cause him to be thoroughIy (Exodus 21:18-19) heaIed.” It shouId not be Ieft to chance what particuIar medica man shouId treat certain cases. IndustriaI surgery is a specia1 branch and shouId be delegated to those particuIarIy skiIIed in this type of work. A doctor chosmg to do industria1 work shouId educate himseIf aIong these Iines. He shouId have a thorough understanding of compensation Iaws, and shouId cooperate with a11 interested parties to the fuIIest and fairest extent. His duty is to report promptIy to them his findings on examination and his honest opinion of the case. The best work is secured today under conditions whereby medica men are unhampered by the continuous disturbance of economic competition and the frequentty necessary struggIe for existence. It is best for the empIoyee and the empIoyer for an experienced and capabIe surgeon to be paid $100.00 to repair an injured part of the body and secure a resuIt with a disabiIity amounting to $500.00
506
A mrrican
Journal
of Surgery
Flack-Medicolegal
than to pay a doctor who is not skiIied in the handiing of such cases $50.00 and secure a result where the disabiiity wiii be $2,000.00.
The advancement of science and the increase of medicai abiiity has reached such a stage that there shouid no Ionger be a wide divergence of opinion as to the extent and causes of disabiiities. Certainiy, if competent doctors for both sides meet and consult and examine the case, one wiii not estimate a disabiiity at 75 per cent while the other estimates the same disabiiity at 15 per cent. I suggest that competent physicians for both sides examine the case in conference, and without predjudice, before the case is presented to any tribunai. If such procedures were foiIowed, the greatest percentage of cases wouid be settied without triais or contests. When competent doctors examine patients in private practice, the patients are carefuiiy studied, the various angies are impartiaiiy discussed, the questions of diagnosis and treatment are considered over a period of time, particuiarIy if there are any points of difference. After these matters have been considered, after the physicians have read in standard works concerning the various questions, and after carefuI thought has been given about the best interests of the sick person it is not often that there is any great difference of opinion. The reason for this is that the chief interest is in the diagnosis and treatment and is not influenced by any court procedure nor by anything except scientific medicine and the weifare of the patient. Certainiy, after fair consideration, this shouid be the case in arriving at the diagnosis and disabiiity in any injury or alIeged injury, The primary purpose of a medica examination is to determine the facts as based upon a study of the case and shouid not be influenced by any other thought. Frequentiy the interests of an injured person are better served by competent and fair consultations. Such a procedure as this wiii go a iong way in increasing the weight and credence piaced
Examination
DecsMeeR, 1938
upon the testimony of doctors as given in courts. The jury, judges and commissioners arrive at a conciusion concerning the merits of a case by considering factors such as pain, Ioss of function, deformities, and ioss of earning capacity as we11 as factors of IegaI merit. It is necessary, therefore, to present the actua1 and the compIete examination findings, without exaggeration and without underestimating the disabiiities. Of course, there is only one way to prepare a medica case for iegai determination and that is to make an inteiIigent and sufficient examination. This in&ides not oniy a physicai but aiso a mentai study. To make such a survey successfuiIy it is necessary, in the first place, to obtain the confidence of the patient by fair means and by a manifestation of interest. This study shouid be complete and thorough, and shouid estimate, with fairness, the vaiue and weight to be given on the ciaims. It may safeiy be stated that the most carefui and skiifui examination of the patient is for the best interest of the pIaintiff and defendant aIike. A compiete diagnostic survey is necessary in practicaiIy a11 cases which may resuIt in a triai before some court of record. It is not suflicient to stop wit.h an examination which discIoses absent knee jerks, a Rhomberg, and iack of co6rdination. CertainIy, in such a case, a Wassermann test shouid be made, the pupiIIary reflexes shouid be determined, and a compiete neuroiogic examination carried out. If a patient has suffered an injury and compiains of paresthesia of the iower extremities, ataxia, aitered vibratory and position sense, and a parapiegia, and evidence of injury to the pyramidai tracts, the examination should not stop at this piace. A skilfui physician will usuaIiy fmd, on making a carefui biood examination, that pernicious anemia is the cause of the disabihty and that it is not due to iifting on a joint of pipe. Extreme nervousness and trembiing and genera1 debility may be
NEW SERIES VOI_ XLII,
No. 3
Flack-MedicoIegal
found, after a carefuI examination, to be due to muItiple scIerosis. These are onIy a few exampIes showing the necessity for making a compIete examination in any case that is of any consequence. Such an examination may prevent a doctor from being humiliated and discredited in court, when cross examined by a shrewd Iawyer, we11 informed on the particuIar case. A speaker on any subject must keep the kind and cIass of his audience in mind. Different cIasses of audiences demand different expIanations. When any matter is presented, one must consider the kind of peopIe to whom it is presented in order that an expIanation which can be understood wiI1 be made. Otherwise the issue is wasted, time is lost, and the case is not understood. Juries are not composed of doctors, nor of men familiar with technicai medica terms. Judges, commissioners and Iawyers are not doctors and hence are not presumed to be famiIiar with comphcated medica language. In preparing a case to present the facts for study to others than doctors, understandabIe terms and words must be used. Jurors know what one is taIking about when the words, “wrist” and “ ankIe,” are used, but ordinariIy they do not know what is being discussed when such terms as “trapezium,” “scaphoid,” “astragaIus, ” or “OS caIcis” are used. The expIanation of the word, and significance of the term “fracture” must be made cIear to laymen. Fractures of the transverse processes of the spina vertebrae are frequent and they usuaIIy hea by fibrous union and do not show bony union in the x-ray pictures. Such patients practicaIIy always recover and are abIe to carry on their work and have no disability. These are facts estabIished by many hundreds of cases. CertainIy it is not wise to eIaborate about the patient with a broken back and make a11 the impIications that are carried with such statements without some fair expIanation of the particuIar case in point so that it may be reasonabIy understood. The anatomic expIanation that the spinai cord ends at the second Iumbar
Examination
American
Journal
ol Surgery
5T-
vertebra wiI1 throw some Iight on the frequent cIaim that a sIight compression fracture of the fourth or fifth Iumbar vertebra is pressing on the spina cord. The statement that a patient has a broken back, and the aIIusion that he has an injured spina cord must be carefuIIy expIained to the attorney wit.h reference to its significance as to disabiIity. One of the most frequent types of cIaims is for injury of and disabiIity to the back. A Iist of the causes of backache wouId in&de practicaIIy every disease, injury and congenita1 deformity that exists. Due to the frequency of these cIaims, there are a few commonIy accepted points which have been proved by experience and which are based upon anatomic findings with which an attorney shouId be famiIiar. A history of a gradua1 onset of pain which becomes progressiveIy worse is most frequently due to an arthritis or to some disease. The patient shouId be required definiteIy to Iocate the pain and this Iocation shouId be noted. At subsequent examinations it shouId be determined if this Location has changed. Pain in the back due to a genuine injury or a really definite cause does not switch and jump around a11 over the back. It is we11 known that a patient who has a pain in his back which is the resuIt of a sprain of the muscIes or Iigaments has more troubIe and more disabiIity in the morning, after a night’s than he does with moderate rest, exercise. After it has been explained to a Iayman, he is abIe to note some of the physica characteristics of the patient: his buiId, the presence or absence of abnorma1 curves in the spine, whether or not there is tiIting of the pelvis, and other representative findings. AIways examine for the presence of muscle spasm or atrophy in the region of the area compIained of. The motions of the spine are easiIy obtained and can be seen by any Iayman. The patient should be requested to bend to the right and to the Ieft, to bend forward and to bend backward. The Iocation of the pain during these move-
508
A mrrican
Journal
of Surgery
FIack-MedicoIegaI
ments shouId be determined. Be particuIar to ask if the pain is increased or relieved by any one motion. In genuine back pain due to injury, the pain is increased by some motions and reIieved by others. In a rea1 case of injury, the patient does not compIain of severe pain when a11 the various motions of the back are performed. In flexing the back, tensIon is pIaced on certain muscIes which may be painfu1 on account of an injury, but when extension is performed, these muscIes are reIaxed and the pain is reIieved. The significance of vaIuabIe Iaboratory tests wiI1 be Iost unIess a carefu1 and cIear expIanation of their meaning is made to Iaymen. One of the most important points to be brought out during the examination is the history and description of any previous iIIness. Occupation is a matter to be considered because certain occupations pIace a definite strain on certain muscIes and this strain is usuaIIy a continuous one. An effort shouId aIso be made to estimate and determine the type and characteristics of the individua1. Different types of peopIe react differentIy to the same amount of pain. It is necessary to estimate whether the patient is excitabIe or nervous, or is of a phIegmatic disposition. In examining the extremities, measurements can be taken with the tape measure with the expenditure of very IittIe time. Such measurements are very impressive to laymen in determining definite conditions. The subject of fractures of the skuI1 frequentIy presents itseIf. It cannot be too thoroughly emphasized to Iaymen that the skuI1 fracture is not the thing of importance, but that it is the damage to the contents within the skuI1 that is of importance. Always make the more common neuroIogic tests, which require not ski11 so much as time. Determine the condition of the deep tendon reflexes such as the knee jerks, ankIe jerks, biceps and triceps reflexes. Make the usua1 tests for sensory disturbances, such as the distinction between sharp and dull, the abiIity to deter-
Examination
DECEMBER, 1938
mine pain and touch, the vibratory sense and the sense of localization. The significance of the various common findings can, with inteIIigence, be expIained to someone not versed in medicine in such a way that they wiI1 be understood. If anything of an ahnorma nature is found, a carefu1 and more exhaustive examination of the nervous system shouId, of course, be made. Injuries to the skuI1 and spine have so frequentIy been considered by the layman as serious, dangerous and Iasting disabilities and it has been so repeatedIy emphasized that a person with a broken back wiI1 never be abIe to do fuI1 work again that a fair and honest expIanation of the terms and meaning of the particuIar findings in the case shouId be made. EspeciaIIy in medicoIega1 cases is it wise to make repeated examinations and observe the patient over a period of time. We11 do I remember taking care of a man who had compression fractures of the third and fourth Iumbar vertebrae-and they were compressed to an extreme degree. No neuroIogic changes from the norma were present, but definite muscIe spasm was found. When I dismissed him from my care about nine or ten weeks folIowing the injury, I estimated, in good faith, his partia1 permanent disabiIity at 65 per cent. About two years later, this same man, with the same compression fractures, came to my offIce with the statement that he had no disabiIity, that he had no pain, that he feIt himseIf fit in every way to resume any kind of manua1 Iabor. A carefu1 physica examination reveaIed no objective signs of disabiIity, and I feIt that there was no reason why he couId not carry on the same work as before the injury. The mora1 of this experience is that in preparing cases for IegaI presentation, we must impress the fact upon Iaymen that time is a great heaIer and that repeated examinations and observations are frequently necessary for the proper evaluation of the disabiIity in such cases. It must be expIained that x-rays do not determine disabiIity nor Iack of disability.
NEW
SERIES VOL. XLII, No.
3
Flack-MedicoIegaI
X-ray pictures of a fracture that looks terrible may be x-ray pictures of an extremity that has excellent function. Again, of course, the reverse may hold: an x-ray picture may look good, but function of the extremity may be impaired. To determine the presence of an ulnar nerve injury, observe whether the patient can abduct or adduct his fingers. Abduction and adduction are not possible where the ulnar nerve has been injured, for the reason that the ulnar nerve supplies the muscles which control these motions. Similar tests, based on anatomy and sound reasoningtests which are obvious-may be used in different types of cases. Legal cases, involving medical questions, are prepared by doctors and lawyers together and the conditions must be explained in such a way that the reasons are evident to lay minds. Attorneys must have familiarity with the case in order that they may present the matter in an intelligent manner to laymen in order to assist them in reaching logical and reasonable conclusions. Most objective findings are overlooked because not enough time is taken in determining the common conditions and examining for the findings which may be obvious. One should always present all of the facts to the lawyer consulting you, giving him both sides of the case. This is the only fair way and the method necessary to prevent many court surprises and difficult situations. It is advisable, wherever possible, to have the attorney present when examinations are made. Observation is one of the best ways to become familiar with a case, and in this way the attorney has the facts that are important indelibIy impressed upon his mind in such a fashion that he will remember them and they will have a meaning. The question of inguinal hernia due to an injury frequently arises. Of course, we know that an inguina1 hernia, if it is ever traumatic, is extremely rare, but when such a case presents itseif, a complete history is essentia1. It should be considered whether or not the cause could reasonably have any connection with the condition cIaimed.
Examination
American
Journal
of Surgery
309
Other important anatomic and medical ideas and reasons should be carefully discussed with the attorney in connection with such a case. No matter what type of disability or injury is to be tried before a court of record, the points shouId be explained to the attorney in language which he wil1 understand. Reasons for such explanations are given so that the attorney can, in turn, discuss the matter intelligently with the person or persons passing upon the merits of the case. The attorney must understand that certain diseases produce findings that are visible to an intelligent observer. A patient with a definite sciatica walks with a list to one side, and assumes a quiet position without continuous twisting and squirming and jumping around in his chair. In the preparation of a case for legal presentation, if the facts are carefully obtained, without prejudice and presented in terms that can be understood by lawyers, courts and juries, the most important steps in securing an equitable adjustment will have been obtained. It again must be repeated that time and patience are necessary for the proper and fair preparation and presentation of such technical matters to non-medical men. The record of injury, its time, the dates of treatment, the various complaints, the progress notes and the fmdings must all be kept in writing because the doctor will almost certainly be called upon to testify concerning these facts. A doctor handling a large number of cases will not make a proper impression if he relies upon his memory as to a large number of complaints, details and dates. A great part of the reward in the practice of medicine is the pleasure derived from studying and examining cases and discussing them with competent colleagues. This is one of the ways in which we keep up with the advances in medicine. It is best for the patient, and certainly is the most efficient way to prepare a case which is to come up before some tribunal for a hearing on the facts and an estimation of the disabiIity.