Chapter 34 Austin Plant - Plant Family History Group

Mr Samuel Solly, Vice-President of the Royal College of Surgeons Fellow of the Royal Society, surgeon and
lecturer on surgery at St Thomas’s Hospital, was then called and examined with regard to the ward in which
the women died. He gave the same evidence with respect to having visited the wards at night on the 4 th inst.
As that reported in The Times on Tuesday, and then he went on to say: - I recollect No. 24 ward, the female
medical ward. As to paying attention to the state of the ward, I could not enter it without paying attention to
its condition. It was frightfully foul, and I cannot use expressions strong enough to describe its condition
beyond saying it was frightfully foul. I attribute its foul condition to the human exhalations arising from
crowding a great number of people into a small space. The ventilation of this ward and of No. 11 came, I
observed, through the water-closets and the bad smell came, no doubt, in part from the water-closets, so the
stench in the ward was a mixed one. I think such a condition of atmosphere would act upon the inmates so as
to produce a serious apoplexy wherever there was a tendency to it. The blood of the patient would be arrested
in its flow by the condition of the atmosphere, and the result would be an effusion of serum. The postmortem
in this case shows that there had been congestion of the ventricles, and I consider this was owing to
the bad atmosphere of the infirmary. I do think the condition of the ward would hasten the death of a person
labouring under bronchitis. Persons labouring under these diseases needed to have the purest air possible.
With regard to the space question, I was unable to answer positively your question at the inquest on Monday,
with respect to the exact space about to be given at St Tomas’s, and when asked I said about 1,800ft. I have
since made inquiries, and I find that the space given will be 1,800 cubic feet, and in special cases, 2,000.
In answer to the jury, the witness said that he considered it very improbable there would have been effusion
of serum on the brain in the deceased had the necessary space for breathing fresh air, and he did not see one
ward which was unobjectionable. All were bad, but several were extremely bad, and with the exception of
one or two wards for special cases the wards were overcrowded.
A general conversation ensued, in which it was proposed to go and visit the wards. To this a majority of the
jury objected that they were not technically educated so as to judge of the wards, and they would rather trust
to the knowledge conveyed to them by the medical gentlemen that to their own views. Several of the
guardians desired to escort the jurymen round the wards, and seemed somewhat disappointed at this view.
The Coroner proceeded with the case when order had been restored, and the jury returned a verdict – the
Coroner saying it was clear that death had arisen from the overcrowding – that deceased came by her death
“from the mortal effects of an effusion of serum on the brain,” and that the death was “accelerated by
overcrowding and the want of ventilation in the St Pancras Infirmary.”
A juror said something ought to be said in the verdict about the guardians not having taken notice of Dr
Ellis’s report of six weeks since with respect to the want of ventilation.
The Coroner replied that to do that other evidence must be called, and he deprecated such action.
The inquiry into the death of Julia Cowden, aged 30, then opened. This deceased had been in the workhouse
before, and came in a second time 14 days before. She was put into No. 24 ward, in which were 27 beds, and
two on the floor, making 29 patients. Deceased died on Sunday morning. The nurse further said the deceased
had been a hardworking woman. The ward was very close, and the patients complained very much. There
was no artificial means of ventilation of the ward. The evil of overcrowding had been increasing during the
14 months she had been employed in the building.
Dr Ellis, the medical officer gave evidence regarding this death similar to that already given. The post
mortem gave the same indications of congestion of the brain, and the fullness of the ventricles, as in the other
case, and the death arose from the phthisis, accelerated by the bad atmosphere. Dr Ellis said that he had
constantly reported to the guardians of the overcrowded state of the infirmary during two of the five months
he had held the appointment. It was well known that the same thing occurred last winter, but it had come
with increasing force this winter.
The Coroner said Mr Carter, who accompanied Mr Solly, could give the jury independent evidence with
respect to these wards at night.
Mr Robert Brudenell Carter, FRCS, of 8 Princess-street, Hanover-square, stated in answer to questions put by
the Coroner, -“I have been surgeon to great military hospitals in the East, surgeon the ophthalmic hospitals,
and surgeon to the Nottingham Workhouse, I am, therefore, quite familiar with the management of hospitals
and workhouse wards. I accompanied Mr Solly in his visit to these wards and I went into No. 24 ward as well
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