Part 23

Mr. JOHN BROWN ROSS, examined by Mr. GROVE--I am house surgeon to the London Hospital. On 22nd March a labourer, aged thirty-seven, was brought to the hospital about half-past seven in the evening. He had had one paroxysm in the receiving room of our hospital before I saw him. He had a rapid but feeble pulse, breathing quickly though not laboriously. The jaws were closed and fixed, there was an expression of anxiety about the countenance, and the features were sunken. He was unable to swallow, the muscles of the abdomen and back were somewhat tense. After he had been in the ward about ten minutes he had another paroxysm and opisthotonos, which lasted about one minute. He was then quiet for a few minutes; he had then another, and died. He had only been in the hospital about half an hour. An inquest was held on the body, but no poison was found. I attribute the cause of death to tetanus. There were three wounds, two on the back of the right elbow, about the size of a shilling each, and one on the left elbow, about the size of a sixpence. The man told me he had had them about twelve or sixteen years. They were old, chronic, indurated ulcers, circular in outline, the edges thickened round, undermined, and covered with a dirty white coating without any granulations. I am unable to say what produced those ulcers. I have seen old, chronic syphilitic wounds in the legs similar to those in the elbow, but I cannot say that these were so. These wounds were the only things to account for tetanus. There was no other cause found.

Cross-examined by the ATTORNEY-GENERAL--I learned from the man’s wife that a linseed meal poultice had been applied to this ulcer a day or two before. The jaws were completely fixed when he came, so as to render him incapable of swallowing anything. He said he had just been taken with strange symptoms about the jaws at dinner that morning about eleven o’clock. He was able to speak, though he could not open his jaw. That is the case in tetanus.

Were there also symptoms of rigidity when he was brought in about the abdominal and lumbar muscles; did you learn from him how long this rigidity had been coming on?--Not further than that the first symptoms of the illness he had felt were that morning. He did not say how long he had felt this rigidity about the neck. He was seen by the parish surgeon in the afternoon before coming to the hospital. I have no doubt that the disease had been coming on from the morning.

[Sidenote: J. B. Ross]

Though you cannot speak as to the precise character of these sores, were they ugly sores?--Yes; sores of a chronic character--ulcers. The two on the right elbow were perfectly running into one another. A piece of integument connected the two, so that they would be likely to run into one another eventually. By saying that those sores were undermined I mean that the wounds continued under the skin. There were no signs of healing, and they had the appearance of old, neglected sores.

Were they near the site of any particular nerve?--They were near the ulnar nerve, a very sensitive nerve connected with what we call the “funny bone.”

How soon was he seized with the first paroxysm after he came in?--He had one directly he came into the hospital, but I did not see it. Half an hour from that time he died.

Had he had any paroxysms before he came to the hospital?--I believe he had, all the afternoon.

That was not one continuous paroxysm?--No; there was a twitching of the muscles of the legs and arms.

What are the particular symptoms of the case to which you refer as indicative of death from tetanus?--From the tetanic symptoms and from having wounds.

Put aside for the moment the fact of his having the wounds that would lead to that inference; what were the symptoms that manifested themselves previous to, or concomitantly with, death which you would call tetanic?--The tetanic symptoms there are the lockjaw and the muscles of the abdomen and the back also being rigid; and he complained of pain in his stomach, just over the stomach. I did not hear the account given of the symptoms of Mr. Cook’s death.

Re-examined by Mr. GROVE--Strychnia was suspected in this case before the body was examined. The nerves of the tongue are very delicate ones. There are very delicate nerves at the throat and fauces.

Were you here yesterday when a case was described of an injury in the throat--a sore throat that caused tetanus?--I was.

Are you of opinion that an irritation of the nerves of the throat would cause tetanus as well as the other nerves?--That was produced by exposure to cold; it was therefore idiopathic.

Would any injury to any delicate nerves be a cause of tetanus?--Decidedly.

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[Sidenote: F. Wrightson]

Dr. FRANCIS WRIGHTSON, examined by Mr. KENEALY--I was a pupil of Liebig. I am an analytical chemist and teacher of chemistry at the School of Chemistry at Birmingham. I have studied and made experiments in various poisons, including strychnia. I have not found any extraordinary difficulties in the detection of strychnia. It is detected by the usual tests. I have detected strychnia pure, and I have also discovered it when mixed with impurity, such as bile, bilious matter from putrefying blood, after having separated it from the impurities. Strychnia can be discovered in the tissues. I have discovered it in the viscera of a cat poisoned by strychnia, also in the blood of a dog poisoned by strychnia, also in the urine of another dog poisoned by strychnia. I have heard the theory propounded by Dr. Taylor as to the decomposition of strychnia by the act of poisoning.

Are you of opinion strychnia undergoes decomposition in the act of poisoning?--I am of opinion that it does not. If it were decomposed in the act of poisoning I should say it would not be possible to discover it in the tissues. Portions of strychnia can be discovered in extremely minute quantities indeed. In the first case I mentioned of the detection of strychnia in the blood, 2 grains were given to the dog. One grain was given to the second dog, in which we detected it in the urine. Half a grain was attempted to be administered to the cat, but a considerable portion of it was spilt.

Assuming that a man was poisoned by strychnia, and that his stomach and a portion of his tissues were sent within eight, or nine, or ten days after death for analytical examination, do you say you could discover the poison of strychnia in his remains?--I should have no doubt whatever in saying so.

Cross-examined by the ATTORNEY-GENERAL--Suppose the whole of this poison to be absorbed, where would you expect to find it?--In the blood.

In its progress to its final destination, the destruction of life, does it pass from the blood, or is it left by the blood in the solid tissues of the body before it produces that effect?--I cannot tell.

If it has passed from the stomach by absorption in the blood, the whole dose, into the circulation, do you say you would still expect to find any of it?--Decidedly so, because I believe it exists as strychnia in the blood.

Do you say you would still expect to find any of it in the stomach?--In order to be absorbed it must be dissolved, and in that portion of the fluid which surrounds the coats of the stomach I should expect to find it.

Suppose the whole to be absorbed?--Then I should not detect it.

Suppose the whole of it has been eliminated from the blood and passed from the system?--Certainly not.

LORD CAMPBELL--You would expect to find it elsewhere, not in the stomach?--Yes. I would expect to find it in the blood and in the tissues.

[Sidenote: F. Wrightson]

Cross-examination resumed--My question only supposes the minimum of the dose that will destroy life to have been given; and, supposing that to have been absorbed into the circulation, and there deposited in the tissues, or part of it eliminated by the action of the kidneys, would you know where to search for it?--I should search for it both in the blood and in the tissues, and in the ejecta of the kidneys; and from my experiments I should expect to find it in each of them, in case the urine was not ejected during the time of poisoning.

Re-examined by Mr. SERJEANT SHEE--If a man had been killed by strychnia, administered an hour and a half before he died, the poison would certainly be detected in the stomach in the first instance.

Supposing it to have been administered in the shape of pills, would it by that time have been all absorbed and circulated in the system so as to get out of the stomach?--I cannot tell. If it were so I would find it in the blood, the liver, and the spleen.

Could you form an opinion whether it could be detected under these circumstances on the coats of the stomach?--Not knowing the dose administered and the powers of absorption, I cannot say with absolute certainty it would be detected, but I should think it in the highest degree probable if a moderate dose had been administered.

Could you form any opinion from the fact that death had taken place after one paroxysm, and in an hour and a half after the ingestion of the poison, whether it was a considerable or an inconsiderable dose?--I cannot give a decided opinion.

LORD CAMPBELL--I cannot allow this gentleman to leave the box without expressing my high approbation of the manner in which he has given his evidence.

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[Sidenote: R. Partridge]

Mr. RICHARD PARTRIDGE, examined by Mr. GROVE--I have been for many years in practice as a surgeon, and am Professor of Anatomy at King’s College. I have heard the evidence as to the symptoms of Mr. Cook and as to the post-mortem examination. In my opinion it is most important in a case of convulsion that the spinal cord should be examined after death. The gritty granules that were found would be likely to cause inflammation of the arachnoid membrane, which would be discoverable if the spinal cord had been examined shortly after death. If examined nine weeks after it is not likely it would be discovered. Although I have not seen such a case, there are cases on record that such inflammation, if it existed, would be capable of producing tetaniform convulsions. The medical term for such inflammation of the arachnoid is arachnitis, or inflammation of the membrane. That disorder produces convulsions and death. I should not say universally; sometimes it does not result in death. I could not form any positive judgment as to the cause of death in Mr. Cook’s case. I have heard the evidence as to the state of contraction after death. No inference at all can be formed of the degree of contraction, or the kind of contraction, that I heard described. If I find the back curved and the body resting on its back and feet after death, I should infer that he died of that form of tetanus which convulses the muscles of the back. Various degrees and varieties of rigidity occur after a natural death. The clenching of the hands or the semi-bending of the feet are not uncommon in cases of ordinary death.

Cross-examined by the ATTORNEY-GENERAL--The granules from which arachnitis might have proceeded were, I understand, situated in the inner surface of the fibrous investment of the cord. They are occasionally found in these parts; not commonly. They are signs. Arachnitis, producing convulsions, has never come under my personal observation, nor has it satisfactorily come under my observation without producing convulsions. It is a very rare disease.

Are you enabled to state from the recorded cases the course of the symptoms of the disease?--No.

Do not you know it to be a disease of considerable duration?--The cases have varied in duration; commonly days at the shortest. Arachnitis is accompanied with paralysis if they live.

Would it, considering the connection that there is between the spinal cord and the brain, affect the brain by sympathy, or otherwise, prior to death?--No.

In these cases, where granules have produced arachnitis, do you happen to know whether the granules have been considerable in point of size?--It has varied in different cases.

Suppose them to be very small and minute?--I should think there would be less likelihood of their producing inflammation.

Suppose an examination at a longer interval than nine days after death failed to detect the inflammation of the arachnoid, that the spinal cord and its integuments had not undergone any decomposition, and that the appearance was perfectly healthy, should you be warranted in inferring there was inflammation?--I should not conclude there was inflammation. Prior to decomposition I should not.

The examination was made by four medical men; are you of opinion that they would be competent judges as to decomposition?--[The question was objected to.]

Does arachnitis not sometimes extend to a matter of months, even where it extends to death?--It might go on for months.

Does it not affect the patient by a series of convulsions at recurring intervals?--That varies.

Did you ever know, or hear of, or read of a case in which the patient died after a single convulsion of arachnitis?--Not a single one.

What would be the concomitant symptoms; would it affect the rest of the patient or affect the general health?--I cannot say.

[Sidenote: R. Partridge]

Do you believe that a man could have twenty-four hours of complete repose?--No.

In the interval between the convulsions could he be quite well?--No; he would have pain and uneasiness according to the situation of the muscles convulsed, the back usually.

You have heard the symptoms, and I presume you have heard from the midnight of Monday till Tuesday Mr. Cook had complete repose. I now ask you if, in the face of the Court and of the profession, you will undertake to say that Mr. Cook’s death proceeded from arachnitis?--I should think not. The majority of the symptoms do not show arachnitis.

You have mentioned that there were one or two of the appearances after death in Cook’s case which would be common to other cases, the semi-closing of the hand. Did you ever know, except in a case of tetanus, the hand so completely clenched as to require force to take the fingers away from the hand?--No, I do not.

Have you ever known the feet to be so distorted as to be described by a medical man as assuming the form of a club foot?--Never.

Did you hear the description given by Mr. Jones that when this man died the body was bowed so that, if he had turned it from its side upon its back, it would have rested on its head and on its heels?--I did.

Have you any doubt that that indicates death from tetanus?--Not from some form of tetanic symptoms. I am only acquainted by reading and hearsay with the symptoms that accompany death from tetanus resulting from the administration of strychnia.

From your knowledge of the subject, having attended to the symptoms described by Mr. Jones from the moment the paroxysm set in of which Mr. Cook died, and the symptoms and appearances attending his death, does it appear that these symptoms are consistent with death by strychnia?--Some are consistent and some are inconsistent. The long interval which occurred after the taking of the poison is inconsistent.

What I am asking you is, whether these symptoms on the Tuesday night, from the time the man was taken with the paroxysms of convulsions of the muscles of the trunk, of the legs, of the arms--the bending of the body into a bow--the difficulty of respiration--are consistent with what you know of death by strychnia?--Quite.

Do you agree that the symptoms in tetanus come on gradually and progressive; that, although they are intermitted, the disease is never wholly remitted?--I do.

What is the shortest period in which you have ever known the disease of traumatic tetanus run its course to death?--Never under three or four days.

[Sidenote: R. Partridge]

Suppose a case could be described as of shorter duration, such as a day or a few hours, would your medical experience lead you to infer that the premonitory symptoms had very likely been neglected?--I should consider that probable.

Bearing in mind the distinction between traumatic and idiopathic tetanus and a case such as has been here described, have you ever seen such a death as this was with the symptoms mentioned proceed from natural causes?--No.

Re-examined by Mr. GROVE--What are the other symptoms which you consider inconsistent with strychnia?--The sickness manifested before the attack came on; the beating of the bed clothes with the arms, want of sensitiveness to external impression, and the sudden cessation of the convulsions, and apparent complete recovery.

You mentioned previously the time that occurred between the ingestion of the poison and the paroxysm coming on. What inference do you deduce from that?--That it is inconsistent with strychnia.

As to the mode in which it came on without premonitory symptoms, do you consider that is inconsistent with strychnia?--There was apparently an absence of the usual condition that is described.

You stated that the bent form indicated some tetaniform symptom. Did that answer apply to natural tetaniform as well as to tetaniform convulsions caused by strychnia?--Yes. The bent form of the feet indicated tetanic spasm. That would be the case whether it was a tetaniform spasm with poison or without poison.

By LORD CAMPBELL--And the other symptoms of rigidity?--It is rather a question of degree.

They would be more violent if from poison?--No doubt.

You have stated in the cases of tetanus you have seen there was no intermission. Do you know, from your reading, that the intermission of the disease is a frequent thing?--I know it occurs, but it is not frequent.

As to decomposition of the spine. Do you think it could remain for nine weeks undecomposed?--I do not.

The ATTORNEY-GENERAL--I have one question which I would put (this gentleman spoke as to vomiting), whether, if the stomach had been brought by any other cause into a state of irritation, would he think those causes inconsistent?

LORD CAMPBELL--I intended to put the question myself.

WITNESS--I should think it not inconsistent.

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[Sidenote: John Gay]

Mr. JOHN GAY, examined by Mr. GRAY--I am a Fellow of the Royal College of Surgeons, and have been for eighteen years a surgeon of the Royal Free Hospital. In the year 1843 I had under my care in the hospital a case of tetanus in a boy eight years old. He was brought in on the 28th of July. The accident occurred a week before. I saw him on the 28th of July. He could not open his mouth at that time. He complained of great pain and stiffness about the neck. During the first three days I saw him he had unusually severe paroxysms.

By LORD CAMPBELL--During the first night of his admission he started up convulsed, and spasmodically closed his jaw. During the following night he was a good deal convulsed at times. The abdominal muscles, as well as the muscles of the neck and back, had become rigid during the night. The muscles of the face were also in a state of great contraction. On the following day I found the muscles remained in the same state. In the morning of that day, at two o’clock, on visiting him I found there was much rigidity of the muscles, especially those of the abdomen and back. The following morning the muscular rigidity had gone. He opened his mouth as usual, and was able to talk. The lad appeared to be thoroughly relieved. He had no return of the spasms till the following day. At that time he asked the nurse to change his linen, and she was lifting him up in bed to do so when violent convulsions of the arms and face came on, and he died in a few minutes.

Examination resumed--About thirty hours elapsed from the time the convulsions of which he died came on and the last preceding convulsions. The last paroxysm before he died lasted a few minutes. Before it came on the rigidity which I have described had been completely relieved. At the time he was convulsed the nurse was lifting him up to put on his linen.

By LORD CAMPBELL--The second day I gave him small doses of tartar emetic to produce vomiting, but without effect. I repeated them in larger doses of 2 grains, but without effect. I did not repeat the dose after the third day.

Cross-examined by the ATTORNEY-GENERAL--What was the accident?--A large stone had fallen on the middle of the left foot and had completely smashed it. The wound had become very unhealthy. When I first saw it it had portions of bone and cartilage adhering to the surface. I amputated the toe. When the boy was brought in his mother said he could not open his mouth so wide as usual. When I saw him his mouth was almost closed up.

On 29th July he slept but little during the night, and during sleep started up convulsed and spasmodically closed the jaw. The jaw remained closed until the 1st of August. It was closed when I administered tartar emetic to him. In all these cases so trifling a remedy as the tarter emetic is easily given.

[Sidenote: John Gay]

By LORD CAMPBELL--The tongue seems to retain its powers?--Yes. The case is recorded in the _Lancet_.

Cross-examination resumed--After the 29th of July did the convulsions continue throughout the 30th and part of the 31st?--The convulsions came on during the night, and they appear to have remitted during the day, except a muscular rigidity. The tetanus did remain.

But were there no spasms during the daytime?--I believe not.

In the daytime, although there were no convulsions, were the muscles of the body, of the chest, and of the abdominal back and neck all rigid?--Yes. That continued throughout the two days I administered tartar emetic. The rigidity of the muscles and of the stomach would go far to prevent sickness.

You have no doubt that your tartar emetic would have produced its effect but for the rigidity of the muscles?--I suppose it would have done so.

When did the symptoms begin to abate?--On the 1st of August, on the fourth day, and they gradually subsided. They appeared to have subsided during the night. I saw the child during the middle of the day, and I found that they had subsided, and in fact had entirely gone off. I thought he was going to get well.

You told us the woman set him up in bed for the purpose of changing his linen. Would that in any way have brought the toe, that part that had been attacked, into any friction with some parts of the bed?--It must have done so. But I do not think the simple irritation of the toe at that part would have any effect.

But there not having been, in your judgment, nervous irritation set up from the original seat of the disease, can you account in any way for the nervous or muscular disease of tetanus?--If the cause had not entirely gone the symptoms were brought back by the act of sitting up in bed. My impression is there must be some action about the spinal cord as the immediate cause of the symptoms.

Action set up in the spinal cord by irritation of the nerves in the immediate site of the laceration or wound?--Quite so.

May it not be reasonable to infer that any irritation of the part originally injured, exciting or irritating the nerve or the nerves connected with the part, may support its action over the whole system, and so produce convulsion?--I had removed the end of the diseased part, so I cannot conceive that the same cause could exist.

[Sidenote: John Gay]

If you imagine you feel yourself justified in saying that the irritation of the spinal cord once set up continues, why should you infer that the irritation of the nerve may not also continue?--There must be some peculiar irritation of the nerve to give rise to the affection of the spinal cord from which tetanus arises. There appear to be some particular circumstances which produce it.

You have no doubt the state of the toe was the original cause of the convulsions?--I have not.

And that death took place by something or other distinct from the first cause?--Yes.