Letters and papers re: death of J. L. Stanford, 1905-1921

Copy

March 14, 1905

Doctor David Starr Jordan.

Dear Sir: --

After thinking the thing over again I have come to the conclusion that I had better leave the communication relative to my opinion as to the causes of Mrs. Stanford's death, for you to do with as you see fit, should you at any time find it of any service whatever in anything more than a private way, though in all probablility there is no further use you would have for it.

All through the communication I have purposely left out anything whatever in the way of criticism of any doctor connected with the case, with the exception of course of what can be read between the lines. I have said nothing as to the reasons why Dr. Humpris did not put Mrs. Stanford to bed, why Dr. Humphris if he considered it a case of strychnine posisoning whould have allowed Miss Berner and Miss Hunt to keep rubbing her and using all sorts of counter irritation up to the very end etc.

I wish to thank you for your hospitality last evening. I have enjoyed very much having the privelege[sic] of meeting one of whom I have heard and read so much and in whom all college men are especially interested.

Yours sincerely, Ernest C. Waterhouse

Testimony of Dr. Waterhouse

Question. Considering the symptoms, without regard to the fact that strychnine was found to be present in the contents of the intestine, would you be willing to say that Mrs. Stanford died of strychinine poisoning?

Answer. Decidedly not.

In looking over the evidence in regard to the death of Mrs. Stanford I fail to find one characteristic symptom of strychnine poisoning. As far as the testimony of the various witnesses goes, no one saw Mrs. Stanford in a convulsion or spasm until the spasm just preceding death. Mrs. Stanford, when she walked out into the all to call Miss Berner and Miss Hunt, did say she was awakened by a spasm which threw her out of bed, and followed this by saying she thought she had been poisoned. Now, this spasm might have been hysteria, or a mild attack of angina pectoris or a sudden start from a dream due to her indigestion, or what not, but she never would have got up and walked out into the hall immediately after a typical convulsion from strychnine poisoning, and even if she had not got up and walked out into the hall she would have shown signs of extreme exhasution. These were entirely absent, only nervous excitement being present. In fact, she did not even want to sit down when Miss Berner wished her to. But laying this aside, if it were strychnine poisoning, there followed an interval of some twenty-five minutes during which if she were suffereing from strychnine poisoning and had already had one convulsion, she would have been in the highest degree of muscular irritability, the slightest external irritation setting her off into another convulsion, and everything affecting the sensory nerves jarring on the patient. Instead of this, we find that Miss Berner and May Hunt, the maid, were constantly rubbing her, putting her feet in warm water and giving her water to drink, but this did not produce a muscular contraction, nor the sign of a convulsion, nor did she even object to what would set a patient suffering from strychnine poisoning nearly wild, with the single exception of the time, when Miss Berner first asked her to take a drink of warm water to make her vomit and then Mrs. Stanford said she could not, because her jaws were rigid. Miss Berner distinctly states that Mrs. Stanford said this was a rigidity and not a mere queer feeling in the muscles of the jaws such as occasionally comes as a premonitory symptom with other things of strychnine poisoning. Now this is a symptom which in strychnine poisoning usually comes late and only when all the rest of the body is in a violent convulsive seizure, which is the classical diagnostic point between strychnine poisoning and lock jaw. She also, accoring to Miss Berner, said this by opening her mouth and not through closed teeth, and besides this to remedy it Miss Berner rubbed her cheekes "until they were red" which is the very thing which if any of the muscles of the body were rigid already, would have set the patient off into a violent convulsion. Instead of this Miss Berner gets her to take two glasses of warm water after it. Clearly this was hysteria or at least a nervous symptom. Now, in spite of all this internal stimulation, there is not the slightest sign of a convulsion. In the case of strychnine poisoning, surely if there had already been one convulsion, and there was one coming later, the slightest irritation, a draft of air, a bright light, toughing of the patient, giving the patient water to drink, much more the violent rubbing and putting the feet and

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hands in warm water, would have set up a violent convulsion with opisthotonos, muscular twitchings etc.

During all of this time Mrs. Stanford was either standing or sitting, not very characteristic of strychnine poisoning. And now after this very a-typical interval for strychnine poisoning comes the only spasm noted by witnesses and we would expect to see in a convulsion sufficiently strong to cause death, twitchings of individual muscles follwed by violent tetanic convulsions, with opisthotonos (curving backward in an arch) abdominal muscles hard as a board, chest fixed, face livid, eye balls staring, risus sardonicus, and, when there is a slight let up, a slight stimulus setting up a still more violent convulusive seizure. Instead of this strinking picture we find that Mrs. Stanford continues sitting in a chair, the body is not thrown forward, the kees remain flexed, the neck does not become rigid as Miss Berner states who was standing behind her at the time. But Mrs. Stanford simply grips Miss Berner's hands more tightly, and the muscles of her calf stiffen, and her feet turn in somewhat towards the vessel which is between them into which Mrs. Stanford has attempted to vomit. Then she says "Oh! Oh! Oh!" (no contraction around the mouth) and finally Mrs. Stanford's head falls to the side just as Miss Berner disengages one hand to hold Mrs. Stanford's head from falling. Her muscles gradually stiffen but not with the sudden muscular jerking of strychnine poisoning. This is the picture of many deaths which take place in a sitting posture. The very fact that the patient could remain sitting on an ordianry stiff-backed chair would almost rule out a convulsion from strychnine poisoning.

The whole history of the case, so far as can be told from the evidence, lacks entirely the exaggerated reflexes and muscular excitability which is so striking a feature of strychnine poisoning during and between the attacks. Of the fact that this undue sensibility of the sensory and organs sending up a the least stimulus and impulse to the cord and a tremendously exaggerated impulse down to a muscle, being the most characteristic, and par excellence the distinguishing feature of strychnine poisoning, there is no doubt, not only from clinical experience, (the slightest external stimulus setting the patient off into the most marked muscular contractions) but it is also shown by experiments on the lower animals. For instance, Poulsen found that a frog dipped into cocaine solution underwent no convulsion after injecting strychnine, the cocaine used being sufficient to paralize[sic] the cord. Claud Bernard showed this, even more conclusively, by dividing all the posterior (sensory) roots of the spinal nerves of the frog, and then injecting strychnine, when no convulsions occurred except when the proximal ends of the divided nerves were stimulated. Now in Mrs. Stanford's case external stimulation seemed to have just the opposite effect prior to the last, and probably only true spasm, and the whole picture in this spasm looks very much more as though it originated from something other that an external stimulation, as is the case in strychnine poisoning.

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As to the Autopsy. Dr. Wood remarks, in beinning his statement of the autopsy, "there was a most marked rigidity of the muscles such as accompanies strychnine poisoning." Now this autopsy was performed at the time when the rigor mortis was most apt to occur in any case. The characteristic points about the rigidity, following strychnine poisoning, are, first, that it often comes on very early; second, that it often persists for an unusual length of time, (cases have been reported where the rigidity lasted two or three weeks or even two months. Taylor on "Poisons"). For this reason this statement has very little weight when the body was excamined at a lime when rigidity is most common any-way.

This very first statement shows what the doctors at the autopsy expected and were looking for.

2nd Question. Was there any possibility of the death of Mrs. Stanford being due to angina pectoris or anything other than strychnine poisoning?

Answer. Yes.

We have the case of a woman seventy-six year of age. She has over-eaten the afternoon prior to her death and before and after this has taken a long ride which was undue exertion for her. That this gave rise to digestive disturbances is shown first by the fact that she ate no supper that night, and secondly, from the very fact that she wished to take bi-carbonate of soda. There was evidently considerable gas in the stomach pressing against the heart and interfering with its action and leading to considerable distress.

All the symptoms enumerated by thoses witnessing them, up to the spasm at the time of death read from the evidence like those of hysteria.

We have the story from Miss Berner, before Dr. Humpris arrived, that Mrs. Stanford took a few steps into the hall, and said "I am so sick" and again "I have no control of my body" again thinking of her former experience in San Francisco, "I think I am poisoned again." She also said she had been thrown out of bed by a convulsion (spasm B.B.) which woker her up. If this had been a typical strychnine poisoning convulsion she would have known she was poisoned -- nothing is more frightful. These are not the remarks one would expect from one who had had or was having typical convulsions from strychnine posioning. Miss Berner takes the theory of poisoning from Mrs. Stanford and by doing adds to the effect on Mrs. Stanford. She immediately gets water for Mrs. Stanford to drink to cause vomiting. The fact that Miss Berner also believed she had been poisoned (though as a matter of fact it was Mrs. Stanford herself who had put the idea into Miss Berner's head), might make Mrs. Stanford still more apprehensive and when Miss Berner brings her the water Mrs. Stanford is hysterical saying, "I can not drink it, my jaws are so set." Now, as already stated, this symptom comes on late for Mrs. Stanford spoke of this as a real rigidity of the muscles, though Miss Berner state there was none in reality. The very fact that Mrs. Stanford draws attention to it suggests hysteria. Thereupon Miss Berner proceeds to rub her cheeks vigorously, the very think which would have set Mrs. Stanford off into another convulsion, but, on the contrary,

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after this when Miss Berner says, "Try it now," Mrs. Stanford takes two glasses of warm water while Miss Hunt, the maid, and Miss Berner rub her limbs which would also be very likely to set her off into another convulsion much more than mere fanning or a bright light or a mere touch which usually does so. Then on Dr. Humprhis arrival he is told the story of Mrs. Stanford's former experience and told that she thinks she has been poisoned and wishes a stomach-pump to wash out her stomach and he, naturally. until he should find out differently, goes on that supposition. Mrs. Stanford then becomes very apprehensive of death and the fear that she has been poisoned, and is about to die, together with the pressure of the gas in the stomach and possibly the large amount of water (7 glasses), swallowed hastily and overloading the stomach, might readily cause a fatal result from fatty heart or myocarditis or angina pectoris (in the fatal cases there is sometimes no very marked pain).

As to finding no pathological lesion as stated in the autopsy report, Dr. Delafield, one of the leading pathologists of the United States, says, "While in some of the fatal cases of angina pectoris no lesion of the heart or arteries are found, yet in a still larger number such lesion exists." Thus we see that there are some fatal cases of angina pectoris where no pathological condition is found and even when it is found it consists of such easily overlooked lesions as antheroma (thickening) of the coronary arteries (arteries of the heart), or of such lesions which in a case where strychnine poisoning is preconceived theory might not be thought sufficient to cause death as roughening of the arch of the aorta, or myocarditis or fatty heart.

The meager report of the autopsy, however, would not convice me that there was not one or more of these pathological conditions present, to some degree, which, with the great exciting cause, proved fatal.

3rd Question. Considering the fact that strychnine was found in traces in the contents of the intestine, would that fact change your answers to questions 1 and 2?

Answer. No.

Signed: E.C. Waterhouse M.D.