With a view to appreciate and explain the relative importance of each, in enabling the Medical Inquirer and Jurist, to arrive at just conclusions, in cases of complicated doubt and difficulty.
CASE I.
THE PATIENT IS LIVING, AND MEDICAL ASSISTANCE IS REQUIRED.
This is the least complicated case that can occur; the medical inquirer has not only the advantage of the patient’s testimony, but that also of his own observations upon the symptoms and circumstances of the case. We have already stated that the declaration of a person, made under an apprehended pending dissolution, is by the law of this realm considered tantamount to an oath, (see vol. i. p. 165), and we have also stated what it becomes our duty to repeat in this place, that in recording such testimony, we must be prepared to combat various errors and prejudices: we do not mean to deny that the awful situation in which the patient is placed will not, in general, secure us against any wilful misrepresentation, but we contend, that a person acting under the influence of bodily suffering is very apt to fall into numerous fallacies respecting the transactions in which he may have been previously engaged; especially in such cases as usually constitute the objects of medico-judicial inquiry, where the passions not unfrequently increase the natural disturbance of the mind, while the eagerness which is so justly felt for the detection of the author of the injury, will tend rather to heighten than to correct any hallucinations under which the sufferer may happen to labour; for on such occasions the imagination is always ready to supply the want of testimony, and to fill up the spaces which actual observation may have left vacant.
Patients have not unfrequently laboured under the impression of their having taken poison, when there can never have existed the least ground for such a suspicion, and yet their general conduct has been in complete opposition to the idea of insanity:[[1]] a curious case of this kind is related in the Sepulchretum of Bonetus; and even during the progress of the present work, the author was consulted upon an illness, which the patient seriously attributed to the operation of a slow poison, declaring that it had been secretly administered during a philanthropic visit to one of our public prisons. Dr. Esquirol[[2]] also relates the case of a lady, twenty-seven years of age, who in the last stage of phthisis pulmonalis perceived in her room the odour of burning charcoal, and immediately conceived that there was a design against her life; in consequence of which she left her lodging, and sought another abode, but the fumes incessantly pursued her, and she died fully convinced that she was the victim of some malicious persecution.
But of all the fallacies with which we have to contend, no one is more dangerous in its effects, or more frequent in its occurrence, than that which leads them to mistake the identity of the offender; we have already alluded to this fallacy (vol. i. p. 440), and we shall hereafter have occasion to refer to it.
When a medical practitioner is summoned to investigate a case, in which severe sufferings have supervened, without any apparent or assignable cause, the following interrogatories are calculated to elicit data for a just conclusion.
Previous state of the patient, with respect to bodily health and strength?—The knowledge of these facts will materially assist us, not only in explaining the violence of the present symptoms, but in estimating their indications, in forming some opinion with regard to their causes, and in prognosticating their results.
The age and occupation are also to be ascertained. Violent tormina of the bowels, and other symptoms resembling those of acute poisoning, are frequently explained at once, by learning that the individual in question has been engaged in some trade or manufactory, from which he has been necessarily exposed to metallic exhalations; thus painters, gilders, smelters, and others, from living almost constantly in an atmosphere charged with such fumes, are always liable to sudden and violent attacks, dreadful cholics, paralysis, and premature death. See our chapter on the poison of Lead, vol. 2, p. 336, and that on Aerial Poisons, page 457.
Present symptoms of the patient.—Having gained the necessary information with respect to the previous history of our patient, we are prepared to investigate the symptoms under which he at present labours, and to inquire into the circumstances of their accession, progress, order of succession, intensity, and duration. If this investigation be conducted with skill, we shall be enabled to form some opinion respecting the origin of the sufferings, and, perhaps, to distinguish the invasion of a spontaneous disease from the effects of acute poisoning: upon this latter point, however, we shall require the aid of much collateral information,[[3]] as whether the patient has ever suffered in a similar manner at any previous period, or whether any part of his family or friends have experienced a similar attack at the present time? If the reply to this latter query be in the affirmative, we may look for a common cause of the complaint, and be led to suspect that it may arise from the ingestion of some acrid matter. We should therefore proceed to discover the nature of the meals last taken as to quantity and quality; the practitioner should, at the same time, pay particular attention to the state of the different persons affected, and to the existence or absence of vomitings and stools. The following case, reported by Morgagni, and quoted by Orfila & Foderé, may be introduced as affording good illustrations of those points of inquiry, whose importance we are anxious to enforce. “In the month of May, 1711, four persons, that is to say, a priest, two women, one of which was his sister-in-law, and another person, all in good health, and on a journey, stopped at an inn to dine. Setting out on their road after dinner, the priest in a short time felt himself so ill in his bowels, that he was obliged to dismount from his horse. Notwithstanding the copious evacuations, both upwards and downwards, the pain increased every moment, and it was necessary to take the patient back to Céserne, the place where they had dined, and where the priest arrived half dead. A medical man who was called in, thinking he had only to deal with an ordinary cholic, employed a number of fomentations, glysters, purgative draughts, and anodynes; although he saw that one of the women had also strong evacuations with pains and faintings, and that the other person complained of pains and of a weight at the stomach, he never suspected the presence of a poison, because the other woman had no complaint, and the landlord protested with many imprecations, that there was nothing dangerous in his dishes; however, the evacuations saved the patients, and as they diminished a little next morning, it allowed of their removing into the neighbourhood of Morgagni’s residence, whom they immediately called in. This great physician having ascertained whether there was any dish at the table of which the woman who was in good health had not eaten, and having found that it was a great dish of rice which had been first served up, concluded from this circumstance that it was this dish that contained the poison. The difficulty however, was, that the priest who had eaten the least, and who had been on the whole extremely abstemious, was precisely the person who had suffered the most, and the soonest; that the woman, who had eaten more than the priest, had been less sick than he; and that the other person, who had eaten more than all the rest, was the one who was the least incommoded.”