Part 11

Cross-examination continued: Do you not know that very lately there was a case in the London Hospital, a case in which tetanus came on so rapidly and so unaccountably, that it was referred to strychnine, and it was thought necessary to examine the stomach of the patient?--I know that such an opinion was entertained before the history of the case was investigated. I have heard that no strychnine was found. In that case old syphilitic sores were discovered.

By Lord CAMPBELL: I did not see the patient, who was under the care of the house-surgeons, who are now in court.

Cross-examination continued: Might not the irritation of a syphilitic sore, by wet, cold, drink, mercury, and mental excitement, lead to tetanic symptoms?--I do not think that that is very likely. The irritation which is likely to produce tetanus is the sore being exposed to friction, to which syphilitic sores in the throat are not exposed. I should class tetanus arising from the irritation of a sore as “traumatic.” Cases very rarely occur which it is difficult to class as either “traumatic” or “idiopathic.” I should class tetanus arising from irritation of the intestines as “idiopathic.” The character of the spasms of epilepsy is not tetanic.

Not of the spasms; but are not the contractions of epilepsy sometimes continuous, so that the body may be twisted into various forms, and remain rigidly in them?--Not continuously.

For five or ten minutes together?--I think not.

Does it not frequently happen that general convulsions, no cause or trace of which in the form of disease or lesion is to be found in the body after death, occur in the most violent and spastic way, so as to exhibit appearances of tetanic convulsions?--No instance of the kind has come under my observation.

Do you agree with this opinion of Dr. Copeland, expressed in his _Dictionary of Practical Medicine_, under the head “General Convulsions.” “The abnormal contraction of the muscles is in some cases of the most violent and spastic nature, and frequently of some continuance, the relaxations being of brief duration, or scarcely observable, and in others nearly or altogether approaching to tetanic?”--I would rather speak from my own observation. I have not observed anything of the kind.

Does it not happen that a patient dies of convulsions, spastic in the sense of their being tumultuous and alternating, and chronic in the sense of exhibiting continuous rigidity, yet after death no disease is found?--It does not often happen to adults.

Does it sometimes?--I do not know, nor have I read of such a case. I have no hesitation in saying that people may die from tetanus and other diseases without the appearance of morbid symptoms after death.

Are not convulsions not, strictly speaking, tetanic, constantly preserved by retching, distention of the stomach, flatulence of the stomach and bowels, and other dyspeptic symptoms?--Such cases do not come under my observation as a hospital surgeon. I think it is very probable that general convulsions are accompanied by yelling. I don’t know that they frequently terminate fatally, and that the proximate cause of death is spasm of the respiratory muscles, inducing asphyxia.

Re-examined by the ATTORNEY-GENERAL: These convulsions are easily distinguished from tetanus, because in them there is an entire loss of consciousness.

Is it one of the characteristic features of tetanus that the consciousness is not affected?--It is.

Dr. TODD, examined by the ATTORNEY-GENERAL: I am physician at King’s College Hospital, and have held that office about twenty years. I have also lectured on physiology and anatomy, on tetanus and the diseases of the nervous system, and have published my lectures. I agree with the last witness in his distinction between idiopathic and traumatic tetanus. I have seen two cases of what appeared to me to be idiopathic tetanus, but such cases are rare in this country.

By Lord CAMPBELL: I define idiopathic tetanus to be that form of the disease which is produced without any external wound, apparently from internal causes--from a constitutional cause.

Examination resumed: In my opinion, the term “tetanus” ought not to be applied to disease produced by poisons; but I should call the symptoms tetanic, in order to distinguish the character of the convulsions. I have observed cases of traumatic tetanus. Except that in all such cases there is some lesion, the symptoms are precisely the same as those of idiopathic tetanus. The disease begins with stiffness about the jaw. The symptoms gradually develop themselves and extend to the muscles of the trunk.

When the disease has begun is there any intermission?--There are remissions, but they are not complete; only diminutions of the severity of the symptoms--not a total subsidence. The patient does not express himself as completely well, quite comfortable. I speak from my own experience.

What is the usual period that elapses between the commencement and the termination of the disease?--The cases may be divided into two classes. Acute cases will terminate in three or four days, chronic cases will go on as long as from nineteen to twenty-two or twenty-three days, and perhaps longer. I do not think that I have known a case in which death occurred within four days. Cases are reported in which it occurred in a shorter period. In tetanus the extremities are affected, but not so much as the trunk. Their affection is a late symptom. The locking of the jaw is an early one. Sometimes the convulsions of epilepsy assume somewhat of a tetanic character, but they are essentially distinct from tetanus. In epilepsy the patient always loses consciousness. Apoplexy never produces tetanic convulsions. Perhaps I might be allowed to say that when there is effusion of blood upon the brain, and a portion of the brain is involved, the muscles may be thrown into short tetanic convulsions. In such case the consciousness would be destroyed. Having heard described the symptoms attending the death of the deceased, and the _post-mortem_ examination, I am of opinion that in this case there was neither apoplexy nor epilepsy.

The ATTORNEY-GENERAL said that, as Dr. Bamford was so unwell that it was doubtful whether he would be able to appear as a witness, he proposed to put in his deposition, in order to found upon it a question to the witness now under examination.

Dr. TODD and Dr. TWEEDIE deposed that they had seen Dr. Bamford on the previous day, and that he was then suffering from a severe attack of English cholera. He was too unwell to be able to attend and give evidence.

The COURT ruled that the depositions taken before the coroner might be read; and they were accordingly read by the Clerk of Arraigns. They were to the following effect:--

“I attended the late Mr. Cook at the request of Mr. William Palmer. I first saw him about three o’clock on Saturday, the 17th of November, when he was suffering from violent vomiting, the stomach being in that irritable state that it would not contain a teaspoonful of milk. There was perfect moisture of the skin, and he was quite sensible. I prescribed medicine for him, and Mr. Palmer went up to my house and waited till I had made it up, and then took it away. I prescribed a saline medicine, to be taken in an effervescing state. Between seven and eight o’clock in the evening Mr. Palmer again requested me to visit Mr. Cook. The sickness still continued, everything being ejected which he took into his stomach. I gave him two pills as a slight opiate. Mr. Palmer took the pills from my house. I did not accompany him, nor do I know what became of the pills. On the following morning (Sunday) Mr. Palmer again called, and asked me to accompany him. Mr. Cook’s sickness still continued. I remained about ten minutes. Everything he took that morning was ejected from his stomach. Everything he threw up was as clear as water, except some coffee which he had taken. Mr Palmer had administered some pills before I saw Mr. Cook on Saturday, which had purged him several times. Between six and seven o’clock in the evening I again visited the deceased, accompanied by Mr. Palmer. The sickness still continued. I went on Monday morning, between eight and nine o’clock, and changed his medicine. I sent him a draught which relieved him from the sickness, and gave him ease. I did not see him again until Tuesday night, when Mr. Palmer called for me. I examined Mr. Cook in the presence of Mr. Jones and Mr. Palmer, and I observed a change in him. He was irritable and troubled in mind. His pulse was firm, but tremulous, and between 80 and 90. He threw himself down on the bed and turned his face away. He said he would have no more pills nor take any more medicine.”

“After they had left the room Mr. Palmer asked me to make two more pills similar to those on the previous night, which I did, and he then asked me to write the directions on a slip of paper; and I gave the pills to Mr. Palmer. The effervescing mixture contained twenty grains of carbonate of potash, two drachms of compound tincture of cardamine, and two drachms of simple syrup, together with fifteen grains of tartaric acid for each powder. I never gave Mr. Cook a grain of antimony. I did not see the preparations after they were taken away by Mr. Palmer. Mr. Cook did not say he had taken the pills which he had prepared, but he expressed a wish on Sunday and Monday nights to have the pills. His skin was moist, and there was not the least fever about him. When I saw the deceased on Monday he did not say that he had been ill on the Sunday night, but Mr. Palmer told me he had been ill. I considered death to have been the result of congestion of the brain when the _post-mortem_ examination was made, and I do not see any reason to alter that opinion. I have attended other patients for Mr. Palmer. I attended Mrs. Palmer some days before her decease; also two children, and a gentleman from London, who was on a visit at Mr. Palmer’s house, and who did not live many hours after I was called in. The whole of those patients died. Mr. Palmer first made an application to me for a certificate of Mr. Cook’s death on the following Sunday morning, when I objected, saying, “He is your patient.” I cannot remember his reply; but he wished me to fill up the certificate, and I did so. We had no conversation at that time as to the cause of death--nothing more than the opinion I have expressed. Mr. Palmer said he was of the same opinion as myself with respect to the death of the deceased. I never knew apoplexy produce rigidity of the limbs. Drowsiness is a prelude to apoplexy. I attributed the sickness of the first two days to a disordered stomach. Mr. Cook never sent for me himself.”

The examination of Dr. TODD by the ATTORNEY-GENERAL was then proceeded with, as follows: Having heard the deposition of Dr. Bamford read, I do not believe that the deceased died from apoplexy, or from epilepsy. I never knew tetanus arise either from syphilitic sores or from sore throat. There are poisons which will produce tetanic convulsions. The principal of those poisons are nux vomica, strychnine, and bruccia. I have never seen human life destroyed by strychnine, but I have seen animals destroyed by it frequently. The poison is usually given in a largish dose in those cases, so as to put an end to the sufferings and destroy life as soon as possible. I should not like to give a human subject a quarter of a grain. I think that it is not unlikely that half a grain might destroy life; and I believe that a grain certainly would. I think that half a grain would kill a cat. The symptoms which would ensue upon the administration of strychnine, when given in solution--and I believe that poisons of that nature act more rapidly in a state of solution than in any other form--would develope themselves in ten minutes after it was taken, if the dose were a large one; if not so large, they might be half an hour, or an hour before they appeared. Those symptoms would be tetanic convulsions of the muscles--more especially those of the spine and neck; the head and back would be bent back, and the trunk would be bowed in a marked manner; the extremities, also, would be stiffened and jerked out. The stiffness, once set in, would never entirely disappear; but fresh paroxysms would set in, and the jerking rigidity would re-appear; and death would probably ensue in a quarter of an hour or so. The difference between tetanus produced by strychnine and other tetanus is very marked. In the former case the duration of the symptoms is very short, and, instead of being continuous in their development, they will subside if the dose has not been strong enough to produce death, and will be renewed in fresh paroxysms; whereas, in other descriptions of tetanus, the symptoms commence in a mild form, and become stronger and more violent as the disease progresses. The difficulty experienced in breathing is common alike to tetanus, properly so called, and to tetanic convulsions occasioned by strychnine, arising from the pressure upon the respiratory muscles. I think it is remarkable that the deceased was able to swallow, and that there was no fixing of the jaw, which would have been the case with tetanus proper, resulting either from a wound, or from disease. From all the evidence I have heard, I think that the symptoms which presented themselves in the case of Mr. Cook arose from tetanus produced by strychnine.

Cross examined by Mr. GROVE, Q.C.--There are cases sloping into each other, as it were, of every grade and degree, from mild convulsions to violent tetantic spasms. I have published some lectures upon diseases of the brain, and I adhere to the opinion there expressed that the state of a person suffering from tetanus is identical with that which strychnine is capable of producing. In a pathological point of view, an examination of the spinal cord shortly after death, in investigating supposed deaths from strychnine, is important. The signs of decomposition, however, could be easily distinguished from the evidences of disease which existed previously to death; but it would be difficult to distinguish in such a case whether mere softening resulted from decomposition or from pre-existing disease. There is nothing in the _post-mortem_ examination which leads me to think that deceased died from tetanus proper. I think that granules upon the spinal cord, such as I have heard described, would not be likely to cause tetanus. I have not heard of cases treated by Mr. Travers. In animals to which strychnine has been administered I cannot say that I have observed what you call an intolerance of touch; but by touching them the spasms are apt to be excited. That sensibility to touch continues as long as the operation of the poison continues. I have examined the interior of animals that have been killed by strychnine; but I have not observed in such cases that the right side of the heart was usually full of blood. It is some years since I made such an examination; but I am able, nevertheless, to speak positively as to the state of the heart. It was usually empty on both sides. I do not agree with Dr. Taylor, or other authorities, in the opinion that in cases of tetanus animals died asphyxiated. If they did, we should invariably have the right side of the heart full of blood, which is not the case. I think that the term asphyxiated, or suffocated, is often very loosely used. I know from my reading that morphia sometimes produces convulsions; but I believe that they would be of an epileptic character. I think that the symptoms from morphia would be longer deferred in making their appearance than from strychnine; but I cannot speak positively on the point. Morphia, like strychnine, is a vegetable poison. I have not observed in animals the jaw fixed after the administration of strychnine.

Re-examined by the ATTORNEY-GENERAL.--Whatever may be the true theory as to the emptiness of the heart after strychnine, I should say that the heart is more ordinarily empty than filled after tetanus. I think that the heart would be more contracted after strychnine than in ordinary tetanus. I do not believe that a medical practitioner would have any difficulty in distinguishing between ordinary convulsions and tetanic convulsions. I have heard the evidence of the gentlemen who made the _post-mortem_ examination, and I apprehend that there was nothing to prevent the discovery of disease in the spinal cord, had any existed previously to death.

Sir BENJAMIN BRODIE, examined by Mr. JAMES, Q.C.: I have been for many years senior surgeon to St. George’s Hospital, and have had considerable experience as a surgeon. In the course of my practice I have had under my care many cases of death from tetanus. Death from idiopathic tetanus is, according to my experience, very rare in this country. The ordinary tetanus in this country is traumatic tetanus. I have heard the symptoms which accompanied the death of Mr. Cook, and I am of opinion that so far as there was a general contraction of the muscles they resembled those of traumatic tetanus; but as to the course those symptoms took, they were entirely different. I have attended to the detailed description of the attack suffered by Mr. Cook on the Monday night, its ceasing on Tuesday, and its renewal on Tuesday night. The symptoms of traumatic tetanus always begin, so far as I have seen, very gradually, the stiffness of the lower jaw being, I believe, invariably, the symptom first complained of--at least, so it has been in my experience. The contraction of the muscles of the back is always a later symptom--generally much later. The muscles of the extremities are affected in a much less degree than those of the neck and trunk, except in some cases where the injury has been in a limb, and an early symptom has been spasmodic contraction of the muscles of that limb. I do not myself recollect a case of ordinary tetanus in which occurred that contraction in the muscles of the hand which I understand was stated to have taken place in this instance. Again, ordinary tetanus rarely runs its course in less than two or three days, and often is protracted to a much longer period. I knew one case only in which the disease was said to have terminated in so short a time as 12 hours; but probably in that case the early symptoms had been overlooked. Again, I never knew the symptoms of ordinary tetanus to last for a few minutes, then subside, and then come on again after 24 hours. I think that these are the principal points of difference which I perceived between the symptoms of ordinary tetanus and those which I have heard described in this case. I have not witnessed tetanic convulsions from strychnine on animal life. I do not believe that death in the case of Mr. Cook arose from what we ordinarily call tetanus--either idiopathic or traumatic. I never knew tetanus result from sore throat, or from a chancre, or from any other form of syphilitic disease. The symptoms were not the result either of apoplexy or of epilepsy. Perhaps I had better say at once that I never saw a case in which the symptoms that I have heard described here arose from any disease. (Sensation.) When I say that, of course I refer not to particular symptoms, but to the general course which the symptoms took.

Cross-examined by Mr. Serjeant SHEE: I believe I remember one case in the physicians’ ward of St. George’s Hospital, which was shown to me as a case of idiopathic tetanus, but I doubted whether it was tetanus at all. It was a slight case, and I do not remember the particulars.

Considering how rare cases of tetanus are, do you think that the description given by a chambermaid and a provincial medical man, who had never seen but one case, is sufficient to enable you to form an opinion as to the nature of the case?--I must say I thought that the description was very clearly given.

Supposing that they differed in their description, which would you rely upon--the medical man or the chambermaid?

Baron ALDERSON: This is hardly a question to put to a medical witness, although it may be a very proper observation for you to make.

Cross-examination continued: I never knew syphilitic poison produce tetanic convulsions, except in cases where there was disease of the bones of the head.

[Sir Benjamin Brodie gave his evidence with great clearness--slowly, audibly, and distinctly,--matters in which other medical witnesses would do well to emulate so distinguished an example.]

Dr. DANIELL, examined by the ATTORNEY-GENERAL: I was for many years surgeon to the Bristol Hospital, but have been out of practice for some time. In the course of a long practice I should think that I have seen at least thirty cases of tetanus. Two of those were certainly cases of idiopathic tetanus: one of them terminated fatally, the other did not. I quite agree with the other medical witnesses, that idiopathic tetanus is of very rare occurrence in this country. The only difference in the symptoms between idiopathic and traumatic tetanus that I perceived was, that the former were more modified--not so severe--in their character. I was not able to trace these two cases of idiopathic tetanus to any particular cause. I have heard the description given of the symptoms which accompanied the attack upon Mr. Cook before his death, and it appears to me that the circumstances of that attack are assuredly distinguishable from those which came under my experience in dealing with cases of tetanus. The evidence of Sir B. Brodie quite expresses my opinion with respect to the difference of the symptoms between ordinary tetanus and tetanic convulsions produced by strychnine. Tetanus begins with uneasiness in the lower jaw, followed by spasms of the muscles of the trunk, and most frequently extending to the muscles of the limbs. Lock-jaw is almost invariably a symptom of those cases of tetanus--of traumatic tetanus especially. I do not recollect that clinching of the hands is a usual symptom of ordinary tetanus, nor do I remember any twisting of the foot. I do not believe that any of the cases which came under my experience endured for a shorter time than from thirty to forty hours. I never knew a case of syphilitic sore producing tetanus. The symptoms, as they have been described, certainly cannot be referable to apoplexy or epilepsy. I never heard of such a thing. In all the cases of tetanus which came under my observation consciousness has been retained to the last, throughout the whole disease. The symptoms have never set in in their full power from the commencement, but have invariably commenced in a milder form, and have then gone on increasing, being continuous in their character, and without intermission. In my judgment the symptoms in the case of Mr. Cook could not be referred either to idiopathic or traumatic tetanus.

Cross-examined by Mr. GROVE, Q.C.: I have not read Dr. Curling’s or Dr. Copeland’s books on the subject of tetanus; nor have I of late studied much the reported cases. I am not aware that excitement or irritation from vomiting has ever been given as the cause of tetanus. The main symptoms of tetanus are, in my opinion, always very similar, although the inferior symptoms may vary simply. I cannot undertake to say that the convulsions of tetanus arise from the spine. I do not like the term “asphyxia;” but I think that death from tetanic convulsions may probably arise from suffocation. It is many years since I saw a _post mortem_ upon a case of tetanus. I cannot say whether, in the case of death from suffocation, the heart would be full of blood or the reverse. An examination of the spinal cord or marrow never, so far as I know, afforded evidence of the cause to which the tetanus was to be attributed.