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.
* * * * *
[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.
* * * * *
[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.
* * * * *
[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.
Re-examined by Mr. GRAY--I think you told my friend that, with regard to
the convulsions which end in death, you thought they arose from some
irritation set up in the spinal cord?--I did, from that and other
causes.
May the causes of such irritation be very various in different cases?
May the cause of the irritation in the spinal cord which would end in
tetaniform be very various?--I think so.
Suppose in one you have a death accompanied with tetaniform symptoms and
opisthotonos, and the various symptoms of a tetanic character; in the
absence of any knowledge of the case--of the cause you state, probably
the irritation of the spinal cord--do you think it is possible to
ascribe them to any particular cause?--I think it would be extremely
difficult to do so.
Will you give me the proposition you lay down?--In the event of a given
set of symptoms, tetanic symptoms I should say, being proposed, it would
be extremely difficult, if not impossible, without some other evidence,
or collateral evidence, to assign it to any given disease.
LORD CAMPBELL--Or cause?--Or cause.
* * * * *
[Sidenote: W. M‘Donnell]