In June, 1857, six people lost their lives at Cleator Moor, by the respiration of sulphuretted hydrogen in a diluted form, by reason of thei...
In June, 1857, six people lost their lives at Cleator Moor, by the respiration of sulphuretted hydrogen in a diluted form, by reason of their having slept in small, non-ventilated rooms, into which the gas had penetrated. The gas was attributed to slag, which houses were built upon.
Three of the deceased persons — a husband, wife, and child, of one family (Armstrong) — had retired to rest, in their usual health, on the night of the 9th of June. Two of them were found the next morning dead in bed, and a third (the child) was found in a state of insensibility, and lingered until the afternoon of the same day, when she died. The fourth, a healthy adult, retired to sleep in his bed, with his door closed, and he was found dead in an hour. The fifth, a child, was taken ill on the morning of the 11th, and died the same day. The sixth was taken ill on the morning of the 10th, and died on the 12th of June.
The symptoms complained of by some who recovered were nausea, sickness, giddiness, and insensibility. On inspection of the body of one child, the pupils were found dilated — viscid mucus escaped from the nostrils — there was congestion of the lungs and kidneys, as well as of the membranes of the brain. In the adult who died in an hour, the pupils were natural, the jaws firmly clenched, the fingers contracted, and the nails blue ; there was great cadaveric lividity, and a quantity of fluid with frothy mucus issued from the nostrils and mouth. The lungs were much congested, and serum was effused in the cavity of the chest. The heart contained a little fluid blood, and was somewhat flaccid. The membrane of the windpipe and gullet was redder than natural. In the windpipe there was frothy mucus. The stomach, as well as the large and small intestines, were highly congested, but otherwise healthy.
The medical men in attendance having conferred together on the advisability of making a post mortem examination, recommended to the jury that such examination should take place. The jury concurred, and Drs. Fidler and Dixon were appointed to conduct the operation. The inquest was afterwards adjourned until Monday.
The following evidence was then taken: —
William Banton, sworn: I live at Bowthorn Road, in the parish of Cleator, and am a pitman. I knew the whole family of the Armstrongs: I lived next door to them. On Tuesday night I saw them alive, and apparently in good health. The mother had been with my family the night before, and had been in bed nearly all day. I saw the father about six o'clock. As far as I know the house was fastened as usual. During the night I heard the girls crying; but I cannot say how often; I think four times, and each time I went to see if I could get into the house. I knocked once, and called the other times, but could not get any answer. I went to bed myself, but got up again, in consequence of my family being ill. I have a wife and five children, and all were ill except myself. I expected Joseph Armstrong, the son, up about six o'clock, and went to the door, but no one came. I went and consulted my wife as to what we were to do. We thought it would be better to wait an hour expecting some of the children would be up. At the end of the hour I was determined to break into the house, and I went to get assistance. I and Wm. Wray and another man broke into the house. The things in the house were as usual. We went up stairs, and found Joseph Armstrong, junior, and Robert Armstrong, dead in the back room. There were three daughters alive in the same room, who were lying upon their backs in bed insensible. I then went into the front bed-room, and found Joseph Armstrong and Mary Armstrong, his wife, both in bed in a very bad way. They were all in their night dresses, and had evidently been in bed all night. In both of the bedrooms I found a sort of stifling smell. Both the bedroom doors were open, but the windows were closed. I got some vinegar, and bathed the heads of all the persons alive. I had a bottle of medicine which Dr. Thompson had brought for my family, and I gave them part of it. I also gave them a little laudanum. The Armstrongs had lived in the house about three months. On Tuesday morning, about one o'clock, my wife and children began to be ill. I went for Dr. Thompson, a little after two o'clock, and he got to my house a little after four o'clock. Dr. Thompson prescribed for them and stayed about an hour. They were all getting better before he left. They continued sick till about two o'clock in the day when it abated. They were again taken ill at night, and about one o'clock on Wednesday morning they were as bad as they had been before. They continued very ill at night, but when they got up they were better. This was the last of their illness. On the Monday night before the family were taken ill they supped off porridge and milk, which was our usual supper. During their illness they were able to take their food. On Wednesday morning, about two o'clock, I was taken ill myself, but was always able to move about. I had porridge and milk on Tuesday night about half-past ten. The milk, I think, had been got from Mr. Hewitt's, of the mill. I was affected with a singing in my head. It made me stupid, and I could not tell at times what I was about; but when I went into the open air it seemed to relieve me. My house is a shop, and I have to attend to but I have had my family removed to Whitehaven, and I go to sleep there at night. The furnaces of the Hematite Iron Company are about 200 or 300 yards from the house. On Tuesday morning I felt a strong smell in the scullery of my house — something similar to what I felt in Armstrong's but stronger. The houses are built upon slag from the furnaces, and have been occupied about five months. They belong to a Mr. Holliday, of Carlisle. The company have nothing to do with them. I am a collier, and work for the company at No. 2 pit, which is about 700 yards from the works. The houses are numbered; the number of mine is 48. That in which the Armstrongs died is 49; that in which Sloane died is 48; and that in which Fenton Merray died is 44. Sloane died on Thursday morning. Joseph Armstrong, jr., and Robert Armstrong were found dead in bed on Wednesday morning. Mary Armstrong died on Wednesday afternoon, and Joseph Armstrong on Friday morning at No. 1, to which he had been removed from No. 49. The houses are built upon slag, and several of them have a bank of slag behind. The houses with the slag behind are those in which the deaths occurred, with the exception of No. 1. I do not think any of the affected families bought meal at my house. I have sold meal to other families who have not been affected. I do not know whether any of my neighbours got milk from the same place that my family did, but they used the same water that we did. I got my meal from Mr. Hewitt's mill, of Mill Hill. I gave some meal to Dr. Thompson, and some yeast to Dr. Dickson, to be analysed. The meal stands on the floor. It was very wet weather at the time this sickness commenced. The heavy rain commenced on Tuesday morning about one o'clock. In the intervals between the rain it was very hot and sultry. The wind was blowing in the direction from the furnaces and over the slag heap. Both attacks of sickness in my house have occurred in the night time, when the doors were closed. My children first complained of their bowels and head. They were giddy, and lost themselves entirely, being unable to stand. Their eyes were about half open, and their faces were alternately congested and pale. They were not sick till after the doctor had been to them. The door of their room was open, but the window was closed. I and my wife were not ill till we went into the back room. When we came back from Whitehaven I found that she had been taken violently ill and was in a fit. There is no fire-place in the back bed-room, but there is in the front. There is also a fire-place in Armstrong's front bedroom. In the room in which I slept the chimney was open and also the door. In Armstrong's back bedroom, where the two sons were found dead, there was no fire-place. The youngest child was removed from the back bedroom into the front, and this child recovered before any of the rest. In the front room my children were affrighted the second night. I had them removed. As I was going to Whitehaven I staggered, and twice resolved to return home; but by resting against some railings I recovered, and proceeded on. I left my children in charge of the deceased, Mary Armstrong, and after I got back she was taken home ill. She complained of giddiness and pains in her head, and was staggering. I felt a kind of sulphury smell in the scullery of my house, but did not observe it up stairs.
There is no drainage from the houses; the waste water runs out on the slag. The six houses at the top are the only houses with privies; all the contents of the privies remain at the back of the houses, and I have never seen any of it removed. The smell, as I have frequently noticed, is sulphury. In wet weather the water cannot flow away until it is absorbed by the slag under the flags. The flags have all risen up, so much so that some of the doors will scarcely shut.
Mary Hall sworn, said: I am a widow, and live at No. 1, Bowthorn Road. On Wednesday morning I was present when the door of Armstrong's house was broken open. Mrs. Armstrong died at a quarter before 4 o'clock on Wednesday afternoon. She was never able to speak from the first time I saw her till her death. She breathed very badly. Joseph Armstrong, the father, died in my house, and I was present when he died. He was held in the same way, and had the same symptoms as his wife. He died at 20 minutes past 11 o'clock on Friday morning. I have lived at No.1 about five months, and never knew any people similarly affected. I and my family got the same sort of meal, milk, and beer as Banton's family. On going into Armstrong's house I felt a very nasty smell, which quite disordered my own head. It was a similar smell to that caused by throwing water on burning cinders, but not so strong. I felt a dizziness and singing in my ears in consequence of that smell.
Ann Sloane sworn, said: I am wife of Frank Sloane. I knew John Sloane. He worked at the Company's works. He went to his work on Wednesday night, and returned about six on Thursday morning. He got some dry bread and tea, and then went to bed in the back room. My husband and son had slept in the same bed the night before. They went to bed about 9 o'clock, and the son was taken ill during the night. He had been working at the works with his father the day before. My husband left the bed into which Sloane went about 11 o'clock the night before. I went to bed in the kitchen, and on hearing Sloane moaning I went upstairs. I felt a bad smell which affected my chest and caused me to tremble. Sloane was in bed very sick. He could not speak. This was within an hour after he went up. I then went down to get my husband to come home from the furnaces; but as I was so ill and could not get on very fast, I sent a boy forward. I then returned and did all I could to assist the dying man. When I first went up Sloane looked like one dead, and was frothing at the mouth. He breakfasted on tea and bread, as he had always done since he came to live at my house. I delivered the tea to P.C. Fisher, who afterwards gave it to Dr. Thompson for analysis. My own family were using of the same kind of tea, and made with water from the same spot. The water was from the pump at the Bog-houses. He had sugar in his tea, and a sample of the sugar was also taken by the policeman. He had no milk in his tea. During wet weather the water comes under the back door. It stands in a pond in the yard till it sinks away in the earth.
William Banton recalled: I saw the position in which the two Armstrongs, found dead, were lying. Joseph Armstrong, the son, lay on his back with his hands clenched on his breast. The clothes were lying over the hands as if they had never been displaced. Robert was lying on his side, with his face among some matter which had come up from his mouth. Joseph's eyes were open, but Robert's were closed. The elder boy was of a blueish colour, and cold; but the younger was warm.
Frank Sloane sworn, said: John Sloane lived at my house, I got a message at the furnaces to go home. I ran immediately, and found John Sloane on a bed in the back room. He was quite insensible and frothing at the mouth. He remained in that state half an hour, when he died. When he came from his work he was as merry-looking as ever I saw him, and appeared in good health. I went into the same bed myself with my son the night before about nine o'clock, and staid till between eleven and twelve, when my son was taken ill. I felt him beginning to kick, and asked him what ailed him. He said "Nothing." Afterwards I felt him beginning to kick again, and I got up and lifted him out of bed. He vomited on my breast, and was also purged. I carried him downstairs and called for assistance. Two men came in and dashed two bowls of water in his face, and he immediately began to recover. When lying in bed that night I found a sulphury, heavy, bad smell; but I could not say that I was ill myself. The room door was open while I was in bed. I left the door open and it remained so till John Sloane came to it. My two eldest sons were sleeping in the front bedroom that night, but ailed nothing.
Mary Murray, wife of Timothy Murray, miner, sworn, said: — Fenton Murray was my son, and he died on Thursday afternoon. He began to be poorly about one o'clock in the morning: he was purged, but did not vomit. When he began to be ill, I asked him what was the matter with him, and he said his belly was bad. We were sleeping in the front room, and when I got up and opened the door to take the child into the back room, I felt a strong smell of sulphur. I put the child into the bed in the back room, and on returning into the front room I fell down on the floor; I had a pain in my head, and felt dizzy. My husband lifted me up, and went for assistance. I was affected with pains in my head, and had cramps all through my body. I have frequently found a bad smell in the kitchen after rains, so that I was obliged to keep the door shut. We frequently remarked at nights that there was a sulphurous smell. My husband did not ail anything till after he had been out for assistance; but when he was coming upstairs he was taken ill, and became insensible. The eldest child was taken ill in bed in the front room. When the oldest child was taken ill he was removed into the back room, and remained there till he had partly recovered. My husband is very poorly. He has continued ill ever since that night, and is too poorly to be examined here.
Frances Armstrong sworn: — I am sixteen years of age, and am the daughter of Joseph and Mary Armstrong, and lived in No. 49, Bowthorn Road. I remember Tuesday night last. We all had tea about six o'clock. We had fried meat, bread and butter to the tea. We had sugar to the tea, but no milk. Father and mother and the rest of the family, except my brother Joseph and myself, went to bed about nine o'clock. Joseph and I had supper, consisting of coffee, bread, and cheese. We went to bed about ten o'clock. Father and mother slept in the front room, and myself and brothers and sisters in the back room. When I went up to bed, Robert, the deceased, was in bed crying. I asked what he was crying for, but he never spoke. I bathed his head and face in cold water. I did so because we had done so when he was poorly about a fortnight ago; he was then similarly affected. The bathing did him no good. I called to my mother to tell her that Robert was poorly and would not speak; but I got no answer. I got into bed with my brother, and about two minutes afterwards was taken ill. I felt dizzy, and had a pain in my head. I got up, and went to my own bed, but was unable to walk, and had to creep; I could not stand. There would only be about a yard between the beds. I did not get better when I got to my own bed. The door of the room was open, as was also the door of the front bed room. All the casements in the house were closed. I remember lying down in my own bed, where my sister Mary Ann was crying. I asked her what was the matter: she did not answer, but kept crying. I do not remember anything after that, and I remained perfectly insensible till about four o'clock in the following day. In the night one of my sisters was taken into a neighbour's house. We remained there till the following day, when we were taken to the workhouse. I did not feel any bad smell in the house that night, nor on any other occasion. Before going to bed I took a candle into my mother's room for fear some of us should be taken ill. I did so in consequence of all of us having been taken ill about a fortnight ago in a similar way. When we were ill before, my mother and Robert became insensible about an hour. That illness took place in the morning about seven o'clock, before they had got any breakfast. On Sunday morning my mother was again taken ill, and was insensible about an hour. She has never been well since we went into that house, as she always appeared as if she were being smothered. I began to be ill myself on Tuesday night about ten minutes after going into the bedroom. My brother Joseph went upstairs about a quarter of an hour before me, and none of them ever spoke to me after I went up. My brother was ill on Tuesday morning when he got up. I asked him not to go to his work, and he said if he were disposed to be lazy he could stop away. I then fetched my father down to try to stop him; but my father was ill too. My brother was dizzy, and had a pain his head on that morning. When he was determined to go to his work, I gave him some rum and water, and he seemed better after taking it. We got our water from Boghouses, and that was the water the dinner and tea were made of. The fireplace in the front bedroom is covered over with a piece of paper to keep the smoke out; but the chimney was not stopped up. When I recovered, I felt a taste like brimstone in my mouth. On several occasions the children have been ill, and, in consequence, they could not attend Mrs. Attwood's school. I have been ill myself in a similar way. Both my mother and myself have been ill every morning for three weeks. The illness came on in the morning before breakfast. The symptoms were pains in the head, giddiness, and pains in the limbs. My sisters go to Mrs. Attwood's school, at Hazelholme.
Miss Gill sworn, said: I am employed by Mrs. Attwood to teach her school at Hazelholme. I had three scholars of the name of Armstrong — a boy and two girls. They have attended the school about six year's altogether. They were not often off from illness till the family went to reside at Bowthorn Road.
Dr. Fidler was next sworn, and read the following report: -
On Wednesday morning, June 10, 1857, at the request of Dr. Dickson, I went to Cleator Moor to see a family supposed to be poisoned. I took with me a bottle of brandy, the stomach pump, and some sulphate of zinc. I arrived at the house about 20 minutes after 11, and found three children insensible and violently convulsed. Upstairs were a woman and man convulsed, to all appearance sinking. All that was done afterwards was done in conjunction with Dr. Dickson, who conjoins in the following report. John Dixon Fidler, M.D.
We, finding the persons as before stated, by means of the stomach pumps washed out the whole of the stomachs, and injected brandy and water into them. In the case of the man ammonia was added to the brandy and water. Hot coffee with vinegar was afterwards administered, and mustard plasters were freely applied to the bodies and extremities. In the course of five or six hours we considered the two older girls out of danger, the other one not until late in the evening. The woman never showed any signs of improvement, and died at 20 minutes past 2pm. The man appeared to improve once or twice during the day, but he ultimately sank and died on the 12th, about forty-eight hours after we first saw him. We made a post mortem examination of the woman, 44 hours after death. The body was that of a well developed female. There were no external marks more than the usual after death appearances. The cavity of the chest was first opened. There were extensive adhesions of the pleura. The heart was healthy, the right auricle being distended with congulated blood of a coal-black colour. The lungs were congested, but otherwise healthy. The congestion was chiefly on the prosterior part. On opening the cavity of the skull the sinuses of the dura mater were found congested with blood. The spaces between the membranes were congested and full of bloody serous fluid. The abdominal viscera were all healthy. A chemical analysis of the stomach, duodenum, and portion of the small intestines showed no trace of numeral poisoning. The contents of the stomach as procured by the stomach pump, being reserved for future chemical analysis, if required. There was no gaseous smell of any importance, nor was there any vegetable matter or smell of opium, &c, in the stomach. We consider the cause of death to arise from the inhalation of some noxious gas or combination of gasses, the precise nature of which we are not prepared to swear to. We arrive at this conclusion from the nature of the symptoms during life and the absence of anything in the stomach or intestines of a poisonous nature, and the absence of any morbid lesion likely to cause death.
J. D. Fidler, M.D.
J. DICKSON, M.D.
Mr. J. B. Wilson, sworn, read the following evidence: -
On Thursday the 11th of June I was called between nine and ten in the forenoon to visit Timothy Murray and his family, at Cleator Moor. I arrived there about ten and found Timothy Murray, his wife, and younger child in the bed of the front room. Murray and his wife were in a state of great prostration, with a feverish state of the skin and loaded tongues, the pulse of both was quick, they mentioned they had suffered from vomiting and pains in the head and bowels; the younger child was insensible pupils neither dilated or contracted; there was also great rigidity of the hands and sometimes slight convulsive action of the entire frame. The child lingered in this state till half-past three the same afternoon. The elder child was in bed in the back room in a state of prostration; he was brought down to the front room on the ground floor, when he gradually recovered after the use of stimulants, which were given to Murray and his wife with good effect. In the evening, the three were convalescent. In making a post mortem examination of the body I was assisted by Mr. Pearce, of Egremont, and the following is our joint report:-
The post mortem examination of Fenton Murray, aged five years, was made at 1 p.m. on Friday the 12th of June 1857, 21 hours after death.
The body presented the appearance of a well formed child; there was no more than the usual lividity for the period after death. On external examination the pupils were found in a dilated state and the fingers contracted. There was a quantity of viscid mucus flowing from the nose and mouth. On opening the chest there were no abnormal appearances with the exception of congestion at the posterior portion of the lungs, the heart was removed for subsequent investigation.
In the abdominal cavity the stomach externally did not present any peculiar marks; It was removed for the analysis of its contents. The liver was healthy, but the gall — bladder was distended. The large and small intestines were distended with flatus, in other respects healthy. Kidneys natural in structure although congested. The bladder was free from disease and enormously distended with turbid urine. On opening the head the membranes of the brain were seen greatly congested. The structure of this organ was healthy but there was a little serum found in the left ventricle.
J. Bateman Wilson F.R.C.S.
C. W. Pearce, Surgeon.
Previous to analysis the stomach was opened, but the internal coat did not exhibit any congestion, inflammation, or corrosion; there was a quantity of viscid mucus in it.
The stomach and its contents were placed in a glass vessel containing about three ounces of distilled water, and after remaining two hours the liquid was filtered. The following tests were used: — Sitmus indicated the solution to be neutral. Sulphuretted hydrogen, no change. Hydrosulphuret of ammonia, no effect. Nitrate of silver, no precipitate. Sulphate of lime, no change. Oxalate of ammonia, no precipitate. Acetate of lead, no change. Ferro prussinte of potash, neither change of colour nor precipitate. The permarcate and persulphate of iron did not effect any colouring. The water from the well at the back of the second set of cottages adjoining the termination of the railway, was examined with the following tests: — Sulphuretted hydrogen, Hydrosulphate of ammonia, and nitrate of silver without any indications. Oxalate of ammonia gave a precipitate which indicated, but there were no signs of deleterious matter being contained in it. The post mortem appearances and the chemical examination demonstrate that the deceased did not die from the administration of any of the usual poisonous substances, but that death was occasioned by the breathing of a deleterious gas. The symptoms during life, combined with the knowledge of the composition of the materials, which form the ground at the back and the foundation of the houses (and which is called "slag"), lead me to infer that the noxious gas was "Sulphuretted Hydrogen."
Mr. C. W. Pearce, Egremont, sworn, deposed that he concurred in the joint report of the post mortem examination embodied in Mr. Wilson's evidence; but not fully in the opinion Mr. Wilson had given. He had seen cases of poisoning by gases in Staffordshire and other places, but the symptoms were not similar to those presented in these cases.
John Thompson, M.D., Whitehaven, read the following report: —
The body of John Sloane, aged 45, was examined June 12th, about 29 hours after death, in presence of Mr. J. B. Wilson, Dr. Fidler, and Messrs. Pearce and Syme.
External appearance. — Frame moderately stout and well formed, pupils natural, jaws firmly clenched, fingers contracted, nails blue, great cadaveric lividity, a quantity of fluid issuing from the nostrils, and frothy mucus from the nose and mouth. On opening the chest, the lungs were found to be much congested; a quantity of serum was found in the cavity of the chest. The heart contained a little fluid blood, and was somewhat flaccid. The lining membrane of the traches, larynx, and bronchial tubes was much redder than natural, and contained a quantity of frothy mucus. The oesophagus also was much darker than natural. The stomach, large and small intestines, and all the other abdominal viscera were highly congested, but otherwise healthy. The gall bladder distended with a reddish liquid. The brain and its membranes were greatly engorged with blood, which, as in the body generally, was very dark, and of a fluid character. The heart, stomach, part of the small intestines, part of the liver, and part of the spleen, were removed for examination and analysis. The heart was found to be healthy, the stomach contained a reddish, gruel-like fluid; this had an acid reaction. The stomach, part of the liver, and part of the spleen, were tested, but no appearance of poison followed the use of the usual re-agents. I am of opinion that death was caused by the inhalation of some noxious gas or gases, the name of which I am not prepared to state.
(Signed) John Thompson, M.D.
June 15, 1857.
Mr. W. B. Clarke, foreman, said: He was not present at any of the examinations. From all the circumstances of the case, he was of opinion that death had been caused by the inhalation of some poisonous gases.
Mr. Kitchen, builder, Hensingham, on being sworn, said he built the houses, and the foundations of a number of them were on slag from the iron works.
Mr. Randleson said the Coroner need not put that question to witness, as they were ready to admit that all the houses were built upon the slag.
Mr. Postlethwaite and Mr. Armstrong stated that if the inquest were again adjourned, they should be able to adduce evidence to rebut the testimony of the medical gentlemen who had just been examined.
Mr. Randleson said that from all he had heard there was not the least ground for coming to the conclusion that the deaths had been caused by the inhalation of any kind of gas.
Mr. Lumb said if the case were to go to the jury with only the evidence given up to that time, he did not see how they now could give any other verdict than that the deaths had resulted from poisonous gases. If the company were prepared to bring forward evidence to rebut that already given, he should be most happy to receive it. He should send the evidence already taken to the Secretary of State; and it was for the representatives of the Company to consider whether their evidence should not be given before he did so. At present they had only heard one side.
Mr. Postlethwaite said that on that occasion they had attended to hear the nature of the case, but at the next meeting of the jury they should be prepared to give some evidence upon it.
Mr. Clarke then read the letter he had received from the Secretary of State; and, after a short consultation, the jury agreed that, in replying to it, he should again urge upon Sir George Grey to send down some eminent analytical chemist, such a man as Professor Taylor, for instance.
Professor Taylor took his seat at the right of that of the Coroner, through whom he questioned witnesses who were examined on a former occasion, as their depositions were read over by the Clerk.
The Coroner re-opened his court by observing: Gentlemen of the Jury, Shortly after the last adjournment, I sent a copy of the depositions to Sir George Grey, who replied to my letter by stating that Dr. Alfred Taylor had been instructed to come down here and assist in this investigation. Dr. Taylor is now here, and I am sure he will render that assistance which it is so desirable we should have. What I propose to do is to read over the evidence that was taken here the last day; and as the witnesses are here present, Dr. Taylor will have an opportunity of putting any question, which he may deem expedient and necessary on the part of the government. I also wish it to be understood that Dr. Taylor does not attend here as an ordinary witness, but appears here on the part of Her Majesty's government, to assist me, and also to assist you, in coming to a proper decision upon this inquiry. Every assistance you can obtain that will help you to come to a satisfactory conclusion in this inquiry is unquestionably desirable; though I doubt not you will experience no difficulty in coming to a proper decision as to the real cause of the deaths of these unfortunate persons.
The Clerk then proceeded to call witnesses.
William Banton was the first witness whose deposition was read.
Cross-examined by the coroner: I live at No. 48 house. I have a wife and five children. All of my children slept in the back room. My children were all of them ill, more or less. They had never been attacked by a similar illness. The bedroom door was generally open. It was always open. It was open on the night of their illness. The pane of glass in the lattice was shut that night. I think it would be sometimes open in the daytime. I cannot say whether it was open on the day before that night. I never recollect smelling the sulphurous smell in the house so strong as I did on the Tuesday morning, I never recollect smelling it in the house at all before; I smelt it in the scullery house. I also smelt it in the yard. It was a smell something like powder smoke, but a heavier smell. By a heavier smell, I mean that it was a smell more strong than powder smoke is. I still stick to it that it was a smell like sulphur. The smell I smelt on the night of the illness of my children was a sulphurous smell.
I was in the house yesterday with Mr. Clarke. The smell I smelt yesterday was the same I smelt on the night of the illness of my children. I live at No. 48, next door to Armstrong's. I was called into the house by Mr. Clarke. I am living now at No. 27 in the same row. I would know the same sort of smell again if I smelt it. I supplied persons with meal and treacle beer from my shop, who never felt any bad effects from them. The weather was rather wet on Tuesday when my children were taken ill. I cannot say whether there had been rain immediately before or not; it was very close weather. I do not recollect what the Wednesday previous was; I really cannot say. There was a great change in health of my family after I left No. 48 and came to live at No. 27. I had lived at No. 27 before, and the health of my family was always better there than at No. 48. In No. 48 I was troubled with great weakness, and pains in my head. Sometimes I had a sort of trembling all over my body. This feeling would continue when I went to work for a time. When I returned to the house, I was sickly, but not sickly enough to vomit. I did not take my breakfast heartily. I generally breakfasted on tea and dry bread. I cannot tell how much tea and bread I usually took; but I know sometimes more and sometimes less, but never as much as a working man ought. When I first felt the illness came over me, I was in the front room. I slept in the front room, No. 48. No one was with me but my children and my wife. My wife was often in the same way particularly on first getting up. I found her better when I came from work in the afternoon between three and four. I kept the door open generally throughout the day, the back door also. The doors were always open when we went to bed at night. I never felt ill immediately after supper. My wife not being strong, I was frequently in the house at night. My wife has been ill for the last nine or ten weeks. My wife is ill now, but not as she used to be previous to us removing.
The Coroner intimated an opportunity for any gentlemen to put a question to the witness.
Mr. Postlethwaite (to the Coroner); Just ask him (witness) about the ventilation in No. 27 house; ask him whether the ventilation is the same in 48 as it is in No. 27.
Witness: There is one ventilating pane in the back window, and there is a sash window in the front. There is better draft in No. 27 than in No. 48. The back door and the front one is right opposite each other. I have not perceived the same smell in 27 as I did in 48. I smelt the same smell last Sunday night. It was right in at the door. There is not a door at the bottom of the staircase in No. 27; there is in No.48.
By the Coroner: The staircase door at night is generally kept open, but is closed in the day.
Mary Hall's depositions having been read, she was cross-examined by the Coroner: I live at No. 49, I am quite sure that the smell I smelt is like the smell that comes from water thrown upon hot cinders. I didn't perceive the smell in any part of the house except the back bedroom.
The depositions of Ann Sloane were next read.
By the Coroner: John Sloane had not taken anything to eat except what I and the others in the house had taken. He had taken the same a week before and was made ill by eating it. I mean by a bad smell, a weakly bad smell. The heaviness of it made me sleepy. I think it was like sulphur. I had lived in the house three months. As soon as I went into the house, I felt it had a heavy smell. When first I went into Sloane's room that morning I felt a heavy sulphurous smell. I had smelt a sulphurous smell. I don't know what a sulphurous smell comes from; but sometimes when I was lighting the fire I smelt it. I would be lighting a match, but the smell of sulphur came upon me before I lighted the match. Sloane was vomiting in the bed. He was also very frothy at his mouth. It was more than once it would just bulge up out of his mouth. I saw it three or four times. I wiped it off three times, and it came again. I perceived a bad smell from it; and no other body would do it but myself. I was bad myself at the time I helped Sloane. I was sometimes bad myself when I slept in the backroom. If I slept in the daytime I would have a sore head; sore and aching. Two children slept in the backroom. A little lad was taken ill in the room one night, and a girl went to take care of him. She was sick and weak, and took bad every bit of her. She could eat none at all, only drink. The backroom door, when we sleeping in the room was generally shut. The windowpane was mostly shut, when I went up stairs, I went up purposely to open the window, finding a bad smell. The bad smell in the room was the same when first we went to it. I always smelt a bad smell in the backroom. I have seen a kettle boil over into the fire. I think the smell in the backroom was worse than would arise from the boiling over of a kettle of water upon the cinders. I lived at No. 37, next to Banton's. Sloane, during the time he lived with us, never complained of illness. I thought he was a man in fair health. He was always able to go and do his days work as far as I knew.
By Dr. Clarke: I have lived three months in the house. I felt the same smell in the house the first night, or soon afterwards. When the pump goes wrong, the people to obtain a fresh supply would right it again.
By Mr. Attwood: Sloane was employed at the top of the furnace.
By Dr. Clarke: I don't know how long the houses had been completed before we went to occupy one.
The witness Banton was re-called.
By the Coroner: Since I went out, I have been in 48 and 49 houses. In 49, the smell is stronger than ever I smelt yet. No. 49 is now in the same state as on the morning when I found the Armstrongs dead, only there are two flags taken up. Not withstanding the two flags being lifted, the smell is stronger a great deal than I first smelt. The back doors were both open. The depth of the holes where the flags were removed is about a foot in the back premises, and a little more at the front. I left a constable in charge of the whole row. I do not know by whose orders the back doors were opened. When I left yesterday with Dr. Taylor, the doors were both shut.
Frank Sloane, his deposition read, cross-examined by the Coroner: When I went into John Sloan's room he was quite inseusible; I took hold of him, but he did not appear to know that I had hold of him. I saw that he had been vomiting, and was in the room the night before. The child was taken ill about eleven o'clock at night. I got the child up. I did not go into the room after that until going to assist Sloane. The window was shut.
Mary Murray (mother of Fenton Murray, deceased) her depositions read, cross-examined by the Coroner: My number is 44. My husband is not fit to go to work. He got some medicine from Dr. Wilson yesterday. He has a bad cough, and his breathing is bad. He mostly was the worst when we went to bed. The smell got worse at night, and we often had to open the windows at night when we went to bed.
By Dr. Clarke: I have always found the same smell in the back kitchen as upstairs.
By the Coroner: I have smelt a bad smell at the back of the house. I was always ill in my stomach. I never had bad health until I came to that house. My husband has had medicine from the doctor, but I have not. My eldest boy always had his health in No. 44.
By Dr. Clarke: I had a bad cough as soon as I went to that house, which has continued ever since. I think my cough has been better since I left it.
By Dr. Wilson: The back kitchen is damp. I was not so sick in the mornings as at nights.
By Dr. Clarke: I have been repeatedly ill since going into the house.
By Mr. Postlethwaite: The midding stead was cleaned nearly every week during the time we were there.
The depositions of Frances Armstrong were next read, after which she was cross-examined by the Coroner.
By Dr. Clarke: The beds were made that morning about 11 o'clock. The sash in the front room was put up before the beds were made. The back window was also opened. There was a draught through the window on that day.
By the Coroner: There were no slops left in the bedroom on that day. We did not wash ourselves upstairs.
By Dr. Clarke: My mother did not say anything about being attacked. She thought her illness was owing to the air.
By the Coroner: When the door was open there was no smell. There was no smell in the room at night either. There was no smell in the room when I came down in the morning. I didn't feel anything likely to choke me upon first going into the room that night.
By Dr. Fidler: I do not remember what month it was my father went away.
By the Coroner: My father would be from home longer than six months, I think, but I don't know the exact time.
By Mr. Postlethwaite: The door at the bottom of the staircase was open on that night.
By Mr. Attwood: My brother and sister were not affected in the same manner as my mother.
By the Coroner: My brother and sister had been ill about a fortnight. My brother felt ill when he was at work.
James Kitchin, builder, Hensingham, was next called and examined by the Coroner: The foundations of the house are levelled in with slag. The outer wall is six or seven feet. There has been more slag placed there since the completion of the houses, which may be three feet, and in some four feet. That slag was taken from the furnaces. The slag was carted from the furnaces. I haven't seen it smoke from fire. I have seen what we call a kind of reek. I have been there when the carts were thrown up. Cinders were also used from the engine-house, but they were not warm when put in. The contract for the houses was, I think, 521 or 531. The rainwater is taken away just over the surface. The rain goes into the background; there are no drains. If the slagheap is high, it will go into foundation.
By Dr. Clarke: The slag was not put in in a concrete manner.
By Mr. Armstrong: At the time the houses were built there was a descent channel to take the water off.
By the Coroner: The water would go down into the foundation.
By Mr. Armstrong: That would be in consequence of the slag not having been heaped up.
John Thompson was the next witness whose deposition was read over.
The deposition of Dr. Wilson, Fidler, Dickson, Thompson, and Clarke were next read.
Mr. Superintendent Clarke was the next witness called.
The Coroner, as Dr. Taylor would require time to make his report, suggested an adjournment till the following day.
The court adjourned accordingly.
Wednesday
The inquiry was resumed this morning at half-past twelve o'clock.
The Coroner was proceeding to take the evidence of Professor Taylor as he would that of an ordinary witness, when Dr. Taylor remarked that it would perhaps be better that he should read to the court the report he had prepared, as that contained nearly the whole of the opinion it might be necessary for him to give. The Coroner acquiescing, the Dr. read his report. It was as follows: -
On Monday, June 22, 1857 in company with Superintendent Clarke, I visited and inspected certain houses in Bowthorn-row, where the various cases of death are reported to have occurred. The houses which were specially visited and inspected were those which are numbered in the plan, No's 49, 48, 47, 46, and 44. No's 16 and 17 were also visited. There was a close unpleasant smell of a similar nature pervading these houses, especially observable in No, 49, which had been closely shut up. It was strongly perceived in the closets, of which the doors had been closed; but particularly in the small back bedroom, except of the house No, 48 (Banton). In the window of this room, two panes of glass had been broken, which allowed of a certain amount of ventilation. The pavement of the floor of the house No. 49 were taken up, back and front; that is, in the front room near the door, and in the back room or kitchen also near to the door an excavation was made to about the depth of a foot in each case. The ground or soil beneath, and in immediate contact with the pavement, was black and damp. It consisted of a black material, resembling ashes, mixed with a quantity of loosely broken slag, the whole forming a loose and porous mass, into which water could easily penetrate. There was no perceptible warmth in these excavations at the time of the visit. A very offensive smell escaped from both holes. It was more copiously emitted from the soil of the back room or kitchen than from that of the front room. The smell thus emitted was similar to that which was perceived in the houses visited and in the closets, but stronger. Test papers were applied in both excavations, at the very bottom of each, and the result was that in the period of half an hour from the time at which these tests were placed in the pit, they clearly, decidedly, and unequivocally indicated the escape of that deadly poisonous gas, sulphuretted hydrogen. In comparing the results it was remarked that the effects were stronger, or the quantity of this gas which escaped was in the same period of time larger in the excavations of the back room than in that of the front room. It was not considered necessary to raise the pavements in any of the other houses. It was understood that all were built on the same plan; that there was no drainage from any one, that the floors of were laid on broken slag, with a thin layer of ashes, and that all the rain water which fell was loosely discharged back and front without any means being provided for this water being carried off. I may remark with regard to the house No, 49, that the window in the lower or front room was a fixture, so that it did not admit of the slightest current of air, and consequently, the only ventilation was by the front door open through the day, but shut at night. The tiles forming the floor are porous, and the junctures are such as to allow of the passage of liquids and gases. The area of this floor I estimated at about 65 square feet, more or less. The upper back room (bed room) was without any means of ventilation, excepting by the door and the small pane of glass in the window, 9 inches by 7 inches. In the houses numbered 49, 48, and 44, it was observed that there were spots of discolouration on the painted woodwork. The doors of the front bedroom, back and front presented these black marks, or stains, in the strongest degree. Portions of the stained woodwork have been cut and tested, and the result of this chemical examination, as well as their appearance, has led me to the conclusion that the black stains have been caused by the action of sulphuretted hydrogen gas upon the paint. The stains in fact, are due to the formation of sulphate of lead. In No. 49 they were found on the woodwork below and above. In No. 48 and 44 they were found chiefly on the woodwork of the front bedroom door, and they unequivocally prove that the sulphuretted hydrogen, as a gas, has been diffused at some period or other in the air of the upper and lower rooms. The house No. 16 was visited. The tiles in the floor were very damp. I was informed that it had been shut up, and not inhabited for some time. On entering there was the usual close offensive smell, perceived more or less in all the houses. The junctions of the tiles in the cement presented a remarkable yellow appearance. This was spread over from 4 to 6 square feet of the tiles, above the centre of the lower front room. A sample of this was collected and has since been analysed. It consists of sulphur, sulphuric acid, oxide of iron, and a small quantity of lime. This is the residue of the decomposition of iron-slag, under the influence of air and water, and after the sulphuretted hydrogen, one of the products of this chemical change, has escaped.
Analysis Of Slag From No. 49
The slag taken from the excavations made in the back and front rooms of 49 contained lime, allumina, carbonate of lime, and a large proportion of sulphide, or what is termed sulphate of iron. There was no sulphide of calcium present.
The Slag Heap
I at the same time inspected the large accumulation of slag collected at the back of the houses. Samples were taken at various points, some from the surface, and others at from one foot to three or more deep. Samples were also taken from the part farthest from the houses, as well as from the part near to them. They all presented much the same composition, and all yielded an abundance of the sulphide or sulphurate of iron. Some portions that were near the surface yielded a large quantity of hydrosulphate of lime. Others from below the surface yielded sulphide of calcium. At a distance of 57 feet from the house No. 49 a hole had been dug to the depth of about three feet, and from this torrents of hot vapour, charged with a large quantity of sulphuretted hydrogen, was at the time issuing. Other parts, when penetrated, also yielded vapour, showing that there was great heat in the mass below. In some parts towards the edge of the bank of slag, it was at a full red heat. About a foot below the surface sulphur had sublimed the fissures of the surface of the heap, resembling the appearance seen in the crater of a volcano. The vapour produced by combustion consisted of aqueous, vapour charged with sulphuric acid.
I may observe that the slag taken from the house No. 49, as well as that from the heap was tested for arsenic, but there was no trace of that poison present in either sample. The slagheap is close to the back wall of the houses numbered from 44 to 49. It is above the level of the back yard in each of these houses, and at the house No. 49 I estimated that it rose at no great distance to a height of from two to three feet above the level of the back yard; hence it follows that any large amount of rain falling on the slag heap will penetrate through the porous slag and find its way under the floors of the houses, chiefly from No. 49 to 46. To a certain extent this would also happen with respect to the house No. 45 and 44, but the slagheap here slopes rapidly in a westerly direction, so that a portion of the rainfall will pass out at the rear without going under the foundations. I caused the foundation of the back wall of the house No. 49 to be laid bare, and saw the bottom of it. The wall extended but a very few inches below the surface of the slag, properly not more than five inches. I found that there was a complete and free communication from the slag of the heap under the back wall to below the whole of the floor of the back and front rooms of the house, so that any large amount of water falling on this heap would find its way in part under the foundations of this and adjoining houses.
The rain discharged from the roof falls on broken surface of the soil, and penetrate into the slag beneath.
The road in front of the houses is raised in the centre so that on one side there is a tendency of the overflow to find its way to the front of the houses.
On Tuesday, June 23rd, 1857 I attended the adjourned inquest held in this place on the bodies of six persons, into the cause of whose death we are met to inquire. The depositions of all the witnesses previously taken were read in my presence. The evidence of other witnesses were taken, and by the courtesy of Mr. Lumb, the coroner, such other questions were put as appeared necessary to the formation of an opinion of the cause of death in these cases.
Applying my mind to the evidence thus adduced, to the inspection of the houses, and the locality where these deaths occurred and aided by experiments which I have been enabled to perform, I have come to the conclusion already arrived at by the medical gentlemen who have given their evidence at this inquest, viz.,
1st. That the six persons deceased, into the cause of whose death we are inquiring, did not die from any natural or unusual form of disease, but that they died from the effects of gaseous poisoning; and my opinion is that the noxious agent was sulphuretted hydrogen.
This gas did not emanate from the iron furnaces, nor from the surface of the slag heap directly; but it proceed from the rainfall (about the period of the calamity) penetrating the heap and washing the sulphuretted hydrogen beneath the foundations of the houses, at the back of which it is piled. Further the contact of water with the sulphide of iron contained in the slag produces this poisonous gas, so that the rainwater already containing sulphuretted hydrogen, produced by contact with the iron slag beneath the houses, a larger amount of this gas would find its way through every crevice or porous material. Thus, then, the action of water on the iron slag is, in my opinion, the cause of the production of this gas. It is going on at all times, in a ratio proportioned to the undercomposed sulphide of iron present, and the quantity of water which finds its access to the foundation. When once there, there is no escape for the gas but through the floor and the whole of the house. Its evolution at the period of the calamity was greater by reason of the heavy rain preceding the occurrence, and the heated state of the atmosphere.
It has been given in evidence that the slag laid beneath the floor of the houses was taken fresh from the iron works when the houses were built, about six months since. As it had not been exposed to the air sufficiently long to decompose the sulphide of iron, it was therefore used in a state most calculated, under a copious supply of water, to produce sulphuretted hydrogen in the largest amount.
That this was the source of the gas, which caused death, appears to me to be proved.
1st. By the discovery of the gas in large quantities, evolved with steam, at a depth of two or three feet below the slagheap.
2nd. By the discovery of the gas actually evolved when the floor was raised on Monday last in the house 49.
3rd. By the presence of such a substance as sulphide of iron in large quantities from the slag of the foundation of the houses as well as from the heap.
4th That there was no other source for its production if we except the presence of sulphide of calcium in the slag heap, which would considerably add to the augment the danger arising from heavy rain falling on the heap. This arises from the fact that sulphide of calcium is instantly and completely decomposed by water, while sulphide of iron is more slowly decomposed.
That the deadly poisonous gas was evolved beneath the floors and penetrated the house, accumulating in those places where there was the least ventilation and no current of air, is provided.
1st. By the discovery of it in the porous soil beneath the floor.
2nd. By its action on patches of paint in the lower room.
3rd. By the discovery on the floor of a damp house, No. 16, which had not been disturbed for some time, of the oxide of iron sulphur, and sulphuric acid.
This material is the result of the decomposition of sulphide of iron in the slag under exposure to air and moisture. It is the solid part of the decomposed slag, while the sulphuretted hydrogen is the gaseous part.
That this gas was the cause of death is proved by the symptoms and appearances taken as a whole. They are similar to, but more severe and fatal, than those, which I witnessed in 1839 in men working at the tunnel under the Thames (Medical Jurisprudence, 5th edition, 791 pp.) The sulphuretted hydrogen was produced by the action of water trickling through the soil on sulphide of iron contained in the soil.
In conclusion, I beg to make this general observation. Every house built on this fresh iron slag is exposed to dangerous accidents of this kind according to the access of water beneath the foundation. The quantity of fresh slag present beneath the foundation, the porousucess or imperfection of the floor, and general want of ventilation in the closets or chambers, having no current or air through there, becoming boxes for the reception and circulation of this poison, and the four houses from No. 49 to 46 are so situated, with respect to the slag heap as to the house of death to all who inhabit them with the doors and windows closed, and under heavy rain falls. None can inhabit them without injury to health, if not danger to life. This danger will exist in all the houses more or less, until the slagheap is entirely decomposed. The houses 49 and 48 will always be dangerous so long as the washing of the slagheap can find their way beneath the foundations.
Alfred Swaine Taylor, M.D, F.R.S
Lecturer on Medical Jurisprudence and Chemistry, Guy's Hospital
The Professor having enlarged, viva voce, on some of the opinions expressed in his report, corroboratively bearing out those opinions, and answered the inquiries of certain of the jury.
The Coroner announced that the case for the Crown was closed, and wished to know of Mr. Postlethwaite whether he proposed to call witnesses.
Mr. Postlethwaite answering negatively.
The Coroner charged the jury at great length, remarking that from the first hearing of the case his opinion had been similar to that entertained by Dr. Bateman Wilson, who was the only medical practitioner who had gone so far as to give a decided opinion as to the cause of death, and which opinion Dr. Taylor had unequivocally confirmed. The Coroner concluded by passing encomiums on various gentlemen, including the jury, whose time and services had been engaged upon no fewer than five occasions during the inquiry.
The jury retired, and after about half-an-hour's deliberation, returned into court with the following.
Verdict
"We find that Joseph Armstrong, the elder, Mary Armstrong, Robert Armstrong, Joseph Armstrong, the younger, John Sloane, and Fenton Murray, have come to their deaths accidentally, and that the cause of death in all these cases has arisen from the inhalation of sulphuretted hydrogen gas, generated from the slag underneath the houses in which they dwelt, and from adjoining heap of the same material.
"W. B. Clarke, Foreman."
In returning the above verdict, the jury recommend that the houses at Bowthorn-row, built upon the slag from the Hematite Works, should be efficiently drained, and all communication with the adjoining slag heap, through the foundations of the houses, be effectively cut off; and the jury are further of opinion that the houses so circumstanced cannot be safely occupied till this is done.
Three of the deceased persons — a husband, wife, and child, of one family (Armstrong) — had retired to rest, in their usual health, on the night of the 9th of June. Two of them were found the next morning dead in bed, and a third (the child) was found in a state of insensibility, and lingered until the afternoon of the same day, when she died. The fourth, a healthy adult, retired to sleep in his bed, with his door closed, and he was found dead in an hour. The fifth, a child, was taken ill on the morning of the 11th, and died the same day. The sixth was taken ill on the morning of the 10th, and died on the 12th of June.
The symptoms complained of by some who recovered were nausea, sickness, giddiness, and insensibility. On inspection of the body of one child, the pupils were found dilated — viscid mucus escaped from the nostrils — there was congestion of the lungs and kidneys, as well as of the membranes of the brain. In the adult who died in an hour, the pupils were natural, the jaws firmly clenched, the fingers contracted, and the nails blue ; there was great cadaveric lividity, and a quantity of fluid with frothy mucus issued from the nostrils and mouth. The lungs were much congested, and serum was effused in the cavity of the chest. The heart contained a little fluid blood, and was somewhat flaccid. The membrane of the windpipe and gullet was redder than natural. In the windpipe there was frothy mucus. The stomach, as well as the large and small intestines, were highly congested, but otherwise healthy.
- An inquest into the deaths of Mrs. Armstrong, Joseph Armstrong, junior, Robert Armstrong, John Sloane, and Fenton Murray was commenced following the tragedy. It was held at the Hematite Iron Company's schoolroom.
The medical men in attendance having conferred together on the advisability of making a post mortem examination, recommended to the jury that such examination should take place. The jury concurred, and Drs. Fidler and Dixon were appointed to conduct the operation. The inquest was afterwards adjourned until Monday.
The following evidence was then taken: —
William Banton, sworn: I live at Bowthorn Road, in the parish of Cleator, and am a pitman. I knew the whole family of the Armstrongs: I lived next door to them. On Tuesday night I saw them alive, and apparently in good health. The mother had been with my family the night before, and had been in bed nearly all day. I saw the father about six o'clock. As far as I know the house was fastened as usual. During the night I heard the girls crying; but I cannot say how often; I think four times, and each time I went to see if I could get into the house. I knocked once, and called the other times, but could not get any answer. I went to bed myself, but got up again, in consequence of my family being ill. I have a wife and five children, and all were ill except myself. I expected Joseph Armstrong, the son, up about six o'clock, and went to the door, but no one came. I went and consulted my wife as to what we were to do. We thought it would be better to wait an hour expecting some of the children would be up. At the end of the hour I was determined to break into the house, and I went to get assistance. I and Wm. Wray and another man broke into the house. The things in the house were as usual. We went up stairs, and found Joseph Armstrong, junior, and Robert Armstrong, dead in the back room. There were three daughters alive in the same room, who were lying upon their backs in bed insensible. I then went into the front bed-room, and found Joseph Armstrong and Mary Armstrong, his wife, both in bed in a very bad way. They were all in their night dresses, and had evidently been in bed all night. In both of the bedrooms I found a sort of stifling smell. Both the bedroom doors were open, but the windows were closed. I got some vinegar, and bathed the heads of all the persons alive. I had a bottle of medicine which Dr. Thompson had brought for my family, and I gave them part of it. I also gave them a little laudanum. The Armstrongs had lived in the house about three months. On Tuesday morning, about one o'clock, my wife and children began to be ill. I went for Dr. Thompson, a little after two o'clock, and he got to my house a little after four o'clock. Dr. Thompson prescribed for them and stayed about an hour. They were all getting better before he left. They continued sick till about two o'clock in the day when it abated. They were again taken ill at night, and about one o'clock on Wednesday morning they were as bad as they had been before. They continued very ill at night, but when they got up they were better. This was the last of their illness. On the Monday night before the family were taken ill they supped off porridge and milk, which was our usual supper. During their illness they were able to take their food. On Wednesday morning, about two o'clock, I was taken ill myself, but was always able to move about. I had porridge and milk on Tuesday night about half-past ten. The milk, I think, had been got from Mr. Hewitt's, of the mill. I was affected with a singing in my head. It made me stupid, and I could not tell at times what I was about; but when I went into the open air it seemed to relieve me. My house is a shop, and I have to attend to but I have had my family removed to Whitehaven, and I go to sleep there at night. The furnaces of the Hematite Iron Company are about 200 or 300 yards from the house. On Tuesday morning I felt a strong smell in the scullery of my house — something similar to what I felt in Armstrong's but stronger. The houses are built upon slag from the furnaces, and have been occupied about five months. They belong to a Mr. Holliday, of Carlisle. The company have nothing to do with them. I am a collier, and work for the company at No. 2 pit, which is about 700 yards from the works. The houses are numbered; the number of mine is 48. That in which the Armstrongs died is 49; that in which Sloane died is 48; and that in which Fenton Merray died is 44. Sloane died on Thursday morning. Joseph Armstrong, jr., and Robert Armstrong were found dead in bed on Wednesday morning. Mary Armstrong died on Wednesday afternoon, and Joseph Armstrong on Friday morning at No. 1, to which he had been removed from No. 49. The houses are built upon slag, and several of them have a bank of slag behind. The houses with the slag behind are those in which the deaths occurred, with the exception of No. 1. I do not think any of the affected families bought meal at my house. I have sold meal to other families who have not been affected. I do not know whether any of my neighbours got milk from the same place that my family did, but they used the same water that we did. I got my meal from Mr. Hewitt's mill, of Mill Hill. I gave some meal to Dr. Thompson, and some yeast to Dr. Dickson, to be analysed. The meal stands on the floor. It was very wet weather at the time this sickness commenced. The heavy rain commenced on Tuesday morning about one o'clock. In the intervals between the rain it was very hot and sultry. The wind was blowing in the direction from the furnaces and over the slag heap. Both attacks of sickness in my house have occurred in the night time, when the doors were closed. My children first complained of their bowels and head. They were giddy, and lost themselves entirely, being unable to stand. Their eyes were about half open, and their faces were alternately congested and pale. They were not sick till after the doctor had been to them. The door of their room was open, but the window was closed. I and my wife were not ill till we went into the back room. When we came back from Whitehaven I found that she had been taken violently ill and was in a fit. There is no fire-place in the back bed-room, but there is in the front. There is also a fire-place in Armstrong's front bedroom. In the room in which I slept the chimney was open and also the door. In Armstrong's back bedroom, where the two sons were found dead, there was no fire-place. The youngest child was removed from the back bedroom into the front, and this child recovered before any of the rest. In the front room my children were affrighted the second night. I had them removed. As I was going to Whitehaven I staggered, and twice resolved to return home; but by resting against some railings I recovered, and proceeded on. I left my children in charge of the deceased, Mary Armstrong, and after I got back she was taken home ill. She complained of giddiness and pains in her head, and was staggering. I felt a kind of sulphury smell in the scullery of my house, but did not observe it up stairs.
There is no drainage from the houses; the waste water runs out on the slag. The six houses at the top are the only houses with privies; all the contents of the privies remain at the back of the houses, and I have never seen any of it removed. The smell, as I have frequently noticed, is sulphury. In wet weather the water cannot flow away until it is absorbed by the slag under the flags. The flags have all risen up, so much so that some of the doors will scarcely shut.
Mary Hall sworn, said: I am a widow, and live at No. 1, Bowthorn Road. On Wednesday morning I was present when the door of Armstrong's house was broken open. Mrs. Armstrong died at a quarter before 4 o'clock on Wednesday afternoon. She was never able to speak from the first time I saw her till her death. She breathed very badly. Joseph Armstrong, the father, died in my house, and I was present when he died. He was held in the same way, and had the same symptoms as his wife. He died at 20 minutes past 11 o'clock on Friday morning. I have lived at No.1 about five months, and never knew any people similarly affected. I and my family got the same sort of meal, milk, and beer as Banton's family. On going into Armstrong's house I felt a very nasty smell, which quite disordered my own head. It was a similar smell to that caused by throwing water on burning cinders, but not so strong. I felt a dizziness and singing in my ears in consequence of that smell.
Ann Sloane sworn, said: I am wife of Frank Sloane. I knew John Sloane. He worked at the Company's works. He went to his work on Wednesday night, and returned about six on Thursday morning. He got some dry bread and tea, and then went to bed in the back room. My husband and son had slept in the same bed the night before. They went to bed about 9 o'clock, and the son was taken ill during the night. He had been working at the works with his father the day before. My husband left the bed into which Sloane went about 11 o'clock the night before. I went to bed in the kitchen, and on hearing Sloane moaning I went upstairs. I felt a bad smell which affected my chest and caused me to tremble. Sloane was in bed very sick. He could not speak. This was within an hour after he went up. I then went down to get my husband to come home from the furnaces; but as I was so ill and could not get on very fast, I sent a boy forward. I then returned and did all I could to assist the dying man. When I first went up Sloane looked like one dead, and was frothing at the mouth. He breakfasted on tea and bread, as he had always done since he came to live at my house. I delivered the tea to P.C. Fisher, who afterwards gave it to Dr. Thompson for analysis. My own family were using of the same kind of tea, and made with water from the same spot. The water was from the pump at the Bog-houses. He had sugar in his tea, and a sample of the sugar was also taken by the policeman. He had no milk in his tea. During wet weather the water comes under the back door. It stands in a pond in the yard till it sinks away in the earth.
William Banton recalled: I saw the position in which the two Armstrongs, found dead, were lying. Joseph Armstrong, the son, lay on his back with his hands clenched on his breast. The clothes were lying over the hands as if they had never been displaced. Robert was lying on his side, with his face among some matter which had come up from his mouth. Joseph's eyes were open, but Robert's were closed. The elder boy was of a blueish colour, and cold; but the younger was warm.
Frank Sloane sworn, said: John Sloane lived at my house, I got a message at the furnaces to go home. I ran immediately, and found John Sloane on a bed in the back room. He was quite insensible and frothing at the mouth. He remained in that state half an hour, when he died. When he came from his work he was as merry-looking as ever I saw him, and appeared in good health. I went into the same bed myself with my son the night before about nine o'clock, and staid till between eleven and twelve, when my son was taken ill. I felt him beginning to kick, and asked him what ailed him. He said "Nothing." Afterwards I felt him beginning to kick again, and I got up and lifted him out of bed. He vomited on my breast, and was also purged. I carried him downstairs and called for assistance. Two men came in and dashed two bowls of water in his face, and he immediately began to recover. When lying in bed that night I found a sulphury, heavy, bad smell; but I could not say that I was ill myself. The room door was open while I was in bed. I left the door open and it remained so till John Sloane came to it. My two eldest sons were sleeping in the front bedroom that night, but ailed nothing.
Mary Murray, wife of Timothy Murray, miner, sworn, said: — Fenton Murray was my son, and he died on Thursday afternoon. He began to be poorly about one o'clock in the morning: he was purged, but did not vomit. When he began to be ill, I asked him what was the matter with him, and he said his belly was bad. We were sleeping in the front room, and when I got up and opened the door to take the child into the back room, I felt a strong smell of sulphur. I put the child into the bed in the back room, and on returning into the front room I fell down on the floor; I had a pain in my head, and felt dizzy. My husband lifted me up, and went for assistance. I was affected with pains in my head, and had cramps all through my body. I have frequently found a bad smell in the kitchen after rains, so that I was obliged to keep the door shut. We frequently remarked at nights that there was a sulphurous smell. My husband did not ail anything till after he had been out for assistance; but when he was coming upstairs he was taken ill, and became insensible. The eldest child was taken ill in bed in the front room. When the oldest child was taken ill he was removed into the back room, and remained there till he had partly recovered. My husband is very poorly. He has continued ill ever since that night, and is too poorly to be examined here.
Frances Armstrong sworn: — I am sixteen years of age, and am the daughter of Joseph and Mary Armstrong, and lived in No. 49, Bowthorn Road. I remember Tuesday night last. We all had tea about six o'clock. We had fried meat, bread and butter to the tea. We had sugar to the tea, but no milk. Father and mother and the rest of the family, except my brother Joseph and myself, went to bed about nine o'clock. Joseph and I had supper, consisting of coffee, bread, and cheese. We went to bed about ten o'clock. Father and mother slept in the front room, and myself and brothers and sisters in the back room. When I went up to bed, Robert, the deceased, was in bed crying. I asked what he was crying for, but he never spoke. I bathed his head and face in cold water. I did so because we had done so when he was poorly about a fortnight ago; he was then similarly affected. The bathing did him no good. I called to my mother to tell her that Robert was poorly and would not speak; but I got no answer. I got into bed with my brother, and about two minutes afterwards was taken ill. I felt dizzy, and had a pain in my head. I got up, and went to my own bed, but was unable to walk, and had to creep; I could not stand. There would only be about a yard between the beds. I did not get better when I got to my own bed. The door of the room was open, as was also the door of the front bed room. All the casements in the house were closed. I remember lying down in my own bed, where my sister Mary Ann was crying. I asked her what was the matter: she did not answer, but kept crying. I do not remember anything after that, and I remained perfectly insensible till about four o'clock in the following day. In the night one of my sisters was taken into a neighbour's house. We remained there till the following day, when we were taken to the workhouse. I did not feel any bad smell in the house that night, nor on any other occasion. Before going to bed I took a candle into my mother's room for fear some of us should be taken ill. I did so in consequence of all of us having been taken ill about a fortnight ago in a similar way. When we were ill before, my mother and Robert became insensible about an hour. That illness took place in the morning about seven o'clock, before they had got any breakfast. On Sunday morning my mother was again taken ill, and was insensible about an hour. She has never been well since we went into that house, as she always appeared as if she were being smothered. I began to be ill myself on Tuesday night about ten minutes after going into the bedroom. My brother Joseph went upstairs about a quarter of an hour before me, and none of them ever spoke to me after I went up. My brother was ill on Tuesday morning when he got up. I asked him not to go to his work, and he said if he were disposed to be lazy he could stop away. I then fetched my father down to try to stop him; but my father was ill too. My brother was dizzy, and had a pain his head on that morning. When he was determined to go to his work, I gave him some rum and water, and he seemed better after taking it. We got our water from Boghouses, and that was the water the dinner and tea were made of. The fireplace in the front bedroom is covered over with a piece of paper to keep the smoke out; but the chimney was not stopped up. When I recovered, I felt a taste like brimstone in my mouth. On several occasions the children have been ill, and, in consequence, they could not attend Mrs. Attwood's school. I have been ill myself in a similar way. Both my mother and myself have been ill every morning for three weeks. The illness came on in the morning before breakfast. The symptoms were pains in the head, giddiness, and pains in the limbs. My sisters go to Mrs. Attwood's school, at Hazelholme.
Miss Gill sworn, said: I am employed by Mrs. Attwood to teach her school at Hazelholme. I had three scholars of the name of Armstrong — a boy and two girls. They have attended the school about six year's altogether. They were not often off from illness till the family went to reside at Bowthorn Road.
Dr. Fidler was next sworn, and read the following report: -
On Wednesday morning, June 10, 1857, at the request of Dr. Dickson, I went to Cleator Moor to see a family supposed to be poisoned. I took with me a bottle of brandy, the stomach pump, and some sulphate of zinc. I arrived at the house about 20 minutes after 11, and found three children insensible and violently convulsed. Upstairs were a woman and man convulsed, to all appearance sinking. All that was done afterwards was done in conjunction with Dr. Dickson, who conjoins in the following report. John Dixon Fidler, M.D.
We, finding the persons as before stated, by means of the stomach pumps washed out the whole of the stomachs, and injected brandy and water into them. In the case of the man ammonia was added to the brandy and water. Hot coffee with vinegar was afterwards administered, and mustard plasters were freely applied to the bodies and extremities. In the course of five or six hours we considered the two older girls out of danger, the other one not until late in the evening. The woman never showed any signs of improvement, and died at 20 minutes past 2pm. The man appeared to improve once or twice during the day, but he ultimately sank and died on the 12th, about forty-eight hours after we first saw him. We made a post mortem examination of the woman, 44 hours after death. The body was that of a well developed female. There were no external marks more than the usual after death appearances. The cavity of the chest was first opened. There were extensive adhesions of the pleura. The heart was healthy, the right auricle being distended with congulated blood of a coal-black colour. The lungs were congested, but otherwise healthy. The congestion was chiefly on the prosterior part. On opening the cavity of the skull the sinuses of the dura mater were found congested with blood. The spaces between the membranes were congested and full of bloody serous fluid. The abdominal viscera were all healthy. A chemical analysis of the stomach, duodenum, and portion of the small intestines showed no trace of numeral poisoning. The contents of the stomach as procured by the stomach pump, being reserved for future chemical analysis, if required. There was no gaseous smell of any importance, nor was there any vegetable matter or smell of opium, &c, in the stomach. We consider the cause of death to arise from the inhalation of some noxious gas or combination of gasses, the precise nature of which we are not prepared to swear to. We arrive at this conclusion from the nature of the symptoms during life and the absence of anything in the stomach or intestines of a poisonous nature, and the absence of any morbid lesion likely to cause death.
J. D. Fidler, M.D.
J. DICKSON, M.D.
Mr. J. B. Wilson, sworn, read the following evidence: -
On Thursday the 11th of June I was called between nine and ten in the forenoon to visit Timothy Murray and his family, at Cleator Moor. I arrived there about ten and found Timothy Murray, his wife, and younger child in the bed of the front room. Murray and his wife were in a state of great prostration, with a feverish state of the skin and loaded tongues, the pulse of both was quick, they mentioned they had suffered from vomiting and pains in the head and bowels; the younger child was insensible pupils neither dilated or contracted; there was also great rigidity of the hands and sometimes slight convulsive action of the entire frame. The child lingered in this state till half-past three the same afternoon. The elder child was in bed in the back room in a state of prostration; he was brought down to the front room on the ground floor, when he gradually recovered after the use of stimulants, which were given to Murray and his wife with good effect. In the evening, the three were convalescent. In making a post mortem examination of the body I was assisted by Mr. Pearce, of Egremont, and the following is our joint report:-
The post mortem examination of Fenton Murray, aged five years, was made at 1 p.m. on Friday the 12th of June 1857, 21 hours after death.
The body presented the appearance of a well formed child; there was no more than the usual lividity for the period after death. On external examination the pupils were found in a dilated state and the fingers contracted. There was a quantity of viscid mucus flowing from the nose and mouth. On opening the chest there were no abnormal appearances with the exception of congestion at the posterior portion of the lungs, the heart was removed for subsequent investigation.
In the abdominal cavity the stomach externally did not present any peculiar marks; It was removed for the analysis of its contents. The liver was healthy, but the gall — bladder was distended. The large and small intestines were distended with flatus, in other respects healthy. Kidneys natural in structure although congested. The bladder was free from disease and enormously distended with turbid urine. On opening the head the membranes of the brain were seen greatly congested. The structure of this organ was healthy but there was a little serum found in the left ventricle.
J. Bateman Wilson F.R.C.S.
C. W. Pearce, Surgeon.
Previous to analysis the stomach was opened, but the internal coat did not exhibit any congestion, inflammation, or corrosion; there was a quantity of viscid mucus in it.
The stomach and its contents were placed in a glass vessel containing about three ounces of distilled water, and after remaining two hours the liquid was filtered. The following tests were used: — Sitmus indicated the solution to be neutral. Sulphuretted hydrogen, no change. Hydrosulphuret of ammonia, no effect. Nitrate of silver, no precipitate. Sulphate of lime, no change. Oxalate of ammonia, no precipitate. Acetate of lead, no change. Ferro prussinte of potash, neither change of colour nor precipitate. The permarcate and persulphate of iron did not effect any colouring. The water from the well at the back of the second set of cottages adjoining the termination of the railway, was examined with the following tests: — Sulphuretted hydrogen, Hydrosulphate of ammonia, and nitrate of silver without any indications. Oxalate of ammonia gave a precipitate which indicated, but there were no signs of deleterious matter being contained in it. The post mortem appearances and the chemical examination demonstrate that the deceased did not die from the administration of any of the usual poisonous substances, but that death was occasioned by the breathing of a deleterious gas. The symptoms during life, combined with the knowledge of the composition of the materials, which form the ground at the back and the foundation of the houses (and which is called "slag"), lead me to infer that the noxious gas was "Sulphuretted Hydrogen."
Mr. C. W. Pearce, Egremont, sworn, deposed that he concurred in the joint report of the post mortem examination embodied in Mr. Wilson's evidence; but not fully in the opinion Mr. Wilson had given. He had seen cases of poisoning by gases in Staffordshire and other places, but the symptoms were not similar to those presented in these cases.
John Thompson, M.D., Whitehaven, read the following report: —
The body of John Sloane, aged 45, was examined June 12th, about 29 hours after death, in presence of Mr. J. B. Wilson, Dr. Fidler, and Messrs. Pearce and Syme.
External appearance. — Frame moderately stout and well formed, pupils natural, jaws firmly clenched, fingers contracted, nails blue, great cadaveric lividity, a quantity of fluid issuing from the nostrils, and frothy mucus from the nose and mouth. On opening the chest, the lungs were found to be much congested; a quantity of serum was found in the cavity of the chest. The heart contained a little fluid blood, and was somewhat flaccid. The lining membrane of the traches, larynx, and bronchial tubes was much redder than natural, and contained a quantity of frothy mucus. The oesophagus also was much darker than natural. The stomach, large and small intestines, and all the other abdominal viscera were highly congested, but otherwise healthy. The gall bladder distended with a reddish liquid. The brain and its membranes were greatly engorged with blood, which, as in the body generally, was very dark, and of a fluid character. The heart, stomach, part of the small intestines, part of the liver, and part of the spleen, were removed for examination and analysis. The heart was found to be healthy, the stomach contained a reddish, gruel-like fluid; this had an acid reaction. The stomach, part of the liver, and part of the spleen, were tested, but no appearance of poison followed the use of the usual re-agents. I am of opinion that death was caused by the inhalation of some noxious gas or gases, the name of which I am not prepared to state.
(Signed) John Thompson, M.D.
June 15, 1857.
Mr. W. B. Clarke, foreman, said: He was not present at any of the examinations. From all the circumstances of the case, he was of opinion that death had been caused by the inhalation of some poisonous gases.
Mr. Kitchen, builder, Hensingham, on being sworn, said he built the houses, and the foundations of a number of them were on slag from the iron works.
Mr. Randleson said the Coroner need not put that question to witness, as they were ready to admit that all the houses were built upon the slag.
Mr. Postlethwaite and Mr. Armstrong stated that if the inquest were again adjourned, they should be able to adduce evidence to rebut the testimony of the medical gentlemen who had just been examined.
Mr. Randleson said that from all he had heard there was not the least ground for coming to the conclusion that the deaths had been caused by the inhalation of any kind of gas.
Mr. Lumb said if the case were to go to the jury with only the evidence given up to that time, he did not see how they now could give any other verdict than that the deaths had resulted from poisonous gases. If the company were prepared to bring forward evidence to rebut that already given, he should be most happy to receive it. He should send the evidence already taken to the Secretary of State; and it was for the representatives of the Company to consider whether their evidence should not be given before he did so. At present they had only heard one side.
Mr. Postlethwaite said that on that occasion they had attended to hear the nature of the case, but at the next meeting of the jury they should be prepared to give some evidence upon it.
Mr. Clarke then read the letter he had received from the Secretary of State; and, after a short consultation, the jury agreed that, in replying to it, he should again urge upon Sir George Grey to send down some eminent analytical chemist, such a man as Professor Taylor, for instance.
- The inquest was then adjourned to Tuesday afternoon next at the same place.
Professor Taylor took his seat at the right of that of the Coroner, through whom he questioned witnesses who were examined on a former occasion, as their depositions were read over by the Clerk.
The Coroner re-opened his court by observing: Gentlemen of the Jury, Shortly after the last adjournment, I sent a copy of the depositions to Sir George Grey, who replied to my letter by stating that Dr. Alfred Taylor had been instructed to come down here and assist in this investigation. Dr. Taylor is now here, and I am sure he will render that assistance which it is so desirable we should have. What I propose to do is to read over the evidence that was taken here the last day; and as the witnesses are here present, Dr. Taylor will have an opportunity of putting any question, which he may deem expedient and necessary on the part of the government. I also wish it to be understood that Dr. Taylor does not attend here as an ordinary witness, but appears here on the part of Her Majesty's government, to assist me, and also to assist you, in coming to a proper decision upon this inquiry. Every assistance you can obtain that will help you to come to a satisfactory conclusion in this inquiry is unquestionably desirable; though I doubt not you will experience no difficulty in coming to a proper decision as to the real cause of the deaths of these unfortunate persons.
The Clerk then proceeded to call witnesses.
William Banton was the first witness whose deposition was read.
Cross-examined by the coroner: I live at No. 48 house. I have a wife and five children. All of my children slept in the back room. My children were all of them ill, more or less. They had never been attacked by a similar illness. The bedroom door was generally open. It was always open. It was open on the night of their illness. The pane of glass in the lattice was shut that night. I think it would be sometimes open in the daytime. I cannot say whether it was open on the day before that night. I never recollect smelling the sulphurous smell in the house so strong as I did on the Tuesday morning, I never recollect smelling it in the house at all before; I smelt it in the scullery house. I also smelt it in the yard. It was a smell something like powder smoke, but a heavier smell. By a heavier smell, I mean that it was a smell more strong than powder smoke is. I still stick to it that it was a smell like sulphur. The smell I smelt on the night of the illness of my children was a sulphurous smell.
I was in the house yesterday with Mr. Clarke. The smell I smelt yesterday was the same I smelt on the night of the illness of my children. I live at No. 48, next door to Armstrong's. I was called into the house by Mr. Clarke. I am living now at No. 27 in the same row. I would know the same sort of smell again if I smelt it. I supplied persons with meal and treacle beer from my shop, who never felt any bad effects from them. The weather was rather wet on Tuesday when my children were taken ill. I cannot say whether there had been rain immediately before or not; it was very close weather. I do not recollect what the Wednesday previous was; I really cannot say. There was a great change in health of my family after I left No. 48 and came to live at No. 27. I had lived at No. 27 before, and the health of my family was always better there than at No. 48. In No. 48 I was troubled with great weakness, and pains in my head. Sometimes I had a sort of trembling all over my body. This feeling would continue when I went to work for a time. When I returned to the house, I was sickly, but not sickly enough to vomit. I did not take my breakfast heartily. I generally breakfasted on tea and dry bread. I cannot tell how much tea and bread I usually took; but I know sometimes more and sometimes less, but never as much as a working man ought. When I first felt the illness came over me, I was in the front room. I slept in the front room, No. 48. No one was with me but my children and my wife. My wife was often in the same way particularly on first getting up. I found her better when I came from work in the afternoon between three and four. I kept the door open generally throughout the day, the back door also. The doors were always open when we went to bed at night. I never felt ill immediately after supper. My wife not being strong, I was frequently in the house at night. My wife has been ill for the last nine or ten weeks. My wife is ill now, but not as she used to be previous to us removing.
The Coroner intimated an opportunity for any gentlemen to put a question to the witness.
Mr. Postlethwaite (to the Coroner); Just ask him (witness) about the ventilation in No. 27 house; ask him whether the ventilation is the same in 48 as it is in No. 27.
Witness: There is one ventilating pane in the back window, and there is a sash window in the front. There is better draft in No. 27 than in No. 48. The back door and the front one is right opposite each other. I have not perceived the same smell in 27 as I did in 48. I smelt the same smell last Sunday night. It was right in at the door. There is not a door at the bottom of the staircase in No. 27; there is in No.48.
By the Coroner: The staircase door at night is generally kept open, but is closed in the day.
Mary Hall's depositions having been read, she was cross-examined by the Coroner: I live at No. 49, I am quite sure that the smell I smelt is like the smell that comes from water thrown upon hot cinders. I didn't perceive the smell in any part of the house except the back bedroom.
The depositions of Ann Sloane were next read.
By the Coroner: John Sloane had not taken anything to eat except what I and the others in the house had taken. He had taken the same a week before and was made ill by eating it. I mean by a bad smell, a weakly bad smell. The heaviness of it made me sleepy. I think it was like sulphur. I had lived in the house three months. As soon as I went into the house, I felt it had a heavy smell. When first I went into Sloane's room that morning I felt a heavy sulphurous smell. I had smelt a sulphurous smell. I don't know what a sulphurous smell comes from; but sometimes when I was lighting the fire I smelt it. I would be lighting a match, but the smell of sulphur came upon me before I lighted the match. Sloane was vomiting in the bed. He was also very frothy at his mouth. It was more than once it would just bulge up out of his mouth. I saw it three or four times. I wiped it off three times, and it came again. I perceived a bad smell from it; and no other body would do it but myself. I was bad myself at the time I helped Sloane. I was sometimes bad myself when I slept in the backroom. If I slept in the daytime I would have a sore head; sore and aching. Two children slept in the backroom. A little lad was taken ill in the room one night, and a girl went to take care of him. She was sick and weak, and took bad every bit of her. She could eat none at all, only drink. The backroom door, when we sleeping in the room was generally shut. The windowpane was mostly shut, when I went up stairs, I went up purposely to open the window, finding a bad smell. The bad smell in the room was the same when first we went to it. I always smelt a bad smell in the backroom. I have seen a kettle boil over into the fire. I think the smell in the backroom was worse than would arise from the boiling over of a kettle of water upon the cinders. I lived at No. 37, next to Banton's. Sloane, during the time he lived with us, never complained of illness. I thought he was a man in fair health. He was always able to go and do his days work as far as I knew.
By Dr. Clarke: I have lived three months in the house. I felt the same smell in the house the first night, or soon afterwards. When the pump goes wrong, the people to obtain a fresh supply would right it again.
By Mr. Attwood: Sloane was employed at the top of the furnace.
By Dr. Clarke: I don't know how long the houses had been completed before we went to occupy one.
The witness Banton was re-called.
By the Coroner: Since I went out, I have been in 48 and 49 houses. In 49, the smell is stronger than ever I smelt yet. No. 49 is now in the same state as on the morning when I found the Armstrongs dead, only there are two flags taken up. Not withstanding the two flags being lifted, the smell is stronger a great deal than I first smelt. The back doors were both open. The depth of the holes where the flags were removed is about a foot in the back premises, and a little more at the front. I left a constable in charge of the whole row. I do not know by whose orders the back doors were opened. When I left yesterday with Dr. Taylor, the doors were both shut.
Frank Sloane, his deposition read, cross-examined by the Coroner: When I went into John Sloan's room he was quite inseusible; I took hold of him, but he did not appear to know that I had hold of him. I saw that he had been vomiting, and was in the room the night before. The child was taken ill about eleven o'clock at night. I got the child up. I did not go into the room after that until going to assist Sloane. The window was shut.
Mary Murray (mother of Fenton Murray, deceased) her depositions read, cross-examined by the Coroner: My number is 44. My husband is not fit to go to work. He got some medicine from Dr. Wilson yesterday. He has a bad cough, and his breathing is bad. He mostly was the worst when we went to bed. The smell got worse at night, and we often had to open the windows at night when we went to bed.
By Dr. Clarke: I have always found the same smell in the back kitchen as upstairs.
By the Coroner: I have smelt a bad smell at the back of the house. I was always ill in my stomach. I never had bad health until I came to that house. My husband has had medicine from the doctor, but I have not. My eldest boy always had his health in No. 44.
By Dr. Clarke: I had a bad cough as soon as I went to that house, which has continued ever since. I think my cough has been better since I left it.
By Dr. Wilson: The back kitchen is damp. I was not so sick in the mornings as at nights.
By Dr. Clarke: I have been repeatedly ill since going into the house.
By Mr. Postlethwaite: The midding stead was cleaned nearly every week during the time we were there.
The depositions of Frances Armstrong were next read, after which she was cross-examined by the Coroner.
By Dr. Clarke: The beds were made that morning about 11 o'clock. The sash in the front room was put up before the beds were made. The back window was also opened. There was a draught through the window on that day.
By the Coroner: There were no slops left in the bedroom on that day. We did not wash ourselves upstairs.
By Dr. Clarke: My mother did not say anything about being attacked. She thought her illness was owing to the air.
By the Coroner: When the door was open there was no smell. There was no smell in the room at night either. There was no smell in the room when I came down in the morning. I didn't feel anything likely to choke me upon first going into the room that night.
By Dr. Fidler: I do not remember what month it was my father went away.
By the Coroner: My father would be from home longer than six months, I think, but I don't know the exact time.
By Mr. Postlethwaite: The door at the bottom of the staircase was open on that night.
By Mr. Attwood: My brother and sister were not affected in the same manner as my mother.
By the Coroner: My brother and sister had been ill about a fortnight. My brother felt ill when he was at work.
James Kitchin, builder, Hensingham, was next called and examined by the Coroner: The foundations of the house are levelled in with slag. The outer wall is six or seven feet. There has been more slag placed there since the completion of the houses, which may be three feet, and in some four feet. That slag was taken from the furnaces. The slag was carted from the furnaces. I haven't seen it smoke from fire. I have seen what we call a kind of reek. I have been there when the carts were thrown up. Cinders were also used from the engine-house, but they were not warm when put in. The contract for the houses was, I think, 521 or 531. The rainwater is taken away just over the surface. The rain goes into the background; there are no drains. If the slagheap is high, it will go into foundation.
By Dr. Clarke: The slag was not put in in a concrete manner.
By Mr. Armstrong: At the time the houses were built there was a descent channel to take the water off.
By the Coroner: The water would go down into the foundation.
By Mr. Armstrong: That would be in consequence of the slag not having been heaped up.
John Thompson was the next witness whose deposition was read over.
The deposition of Dr. Wilson, Fidler, Dickson, Thompson, and Clarke were next read.
Mr. Superintendent Clarke was the next witness called.
The Coroner, as Dr. Taylor would require time to make his report, suggested an adjournment till the following day.
The court adjourned accordingly.
Wednesday
The inquiry was resumed this morning at half-past twelve o'clock.
The Coroner was proceeding to take the evidence of Professor Taylor as he would that of an ordinary witness, when Dr. Taylor remarked that it would perhaps be better that he should read to the court the report he had prepared, as that contained nearly the whole of the opinion it might be necessary for him to give. The Coroner acquiescing, the Dr. read his report. It was as follows: -
On Monday, June 22, 1857 in company with Superintendent Clarke, I visited and inspected certain houses in Bowthorn-row, where the various cases of death are reported to have occurred. The houses which were specially visited and inspected were those which are numbered in the plan, No's 49, 48, 47, 46, and 44. No's 16 and 17 were also visited. There was a close unpleasant smell of a similar nature pervading these houses, especially observable in No, 49, which had been closely shut up. It was strongly perceived in the closets, of which the doors had been closed; but particularly in the small back bedroom, except of the house No, 48 (Banton). In the window of this room, two panes of glass had been broken, which allowed of a certain amount of ventilation. The pavement of the floor of the house No. 49 were taken up, back and front; that is, in the front room near the door, and in the back room or kitchen also near to the door an excavation was made to about the depth of a foot in each case. The ground or soil beneath, and in immediate contact with the pavement, was black and damp. It consisted of a black material, resembling ashes, mixed with a quantity of loosely broken slag, the whole forming a loose and porous mass, into which water could easily penetrate. There was no perceptible warmth in these excavations at the time of the visit. A very offensive smell escaped from both holes. It was more copiously emitted from the soil of the back room or kitchen than from that of the front room. The smell thus emitted was similar to that which was perceived in the houses visited and in the closets, but stronger. Test papers were applied in both excavations, at the very bottom of each, and the result was that in the period of half an hour from the time at which these tests were placed in the pit, they clearly, decidedly, and unequivocally indicated the escape of that deadly poisonous gas, sulphuretted hydrogen. In comparing the results it was remarked that the effects were stronger, or the quantity of this gas which escaped was in the same period of time larger in the excavations of the back room than in that of the front room. It was not considered necessary to raise the pavements in any of the other houses. It was understood that all were built on the same plan; that there was no drainage from any one, that the floors of were laid on broken slag, with a thin layer of ashes, and that all the rain water which fell was loosely discharged back and front without any means being provided for this water being carried off. I may remark with regard to the house No, 49, that the window in the lower or front room was a fixture, so that it did not admit of the slightest current of air, and consequently, the only ventilation was by the front door open through the day, but shut at night. The tiles forming the floor are porous, and the junctures are such as to allow of the passage of liquids and gases. The area of this floor I estimated at about 65 square feet, more or less. The upper back room (bed room) was without any means of ventilation, excepting by the door and the small pane of glass in the window, 9 inches by 7 inches. In the houses numbered 49, 48, and 44, it was observed that there were spots of discolouration on the painted woodwork. The doors of the front bedroom, back and front presented these black marks, or stains, in the strongest degree. Portions of the stained woodwork have been cut and tested, and the result of this chemical examination, as well as their appearance, has led me to the conclusion that the black stains have been caused by the action of sulphuretted hydrogen gas upon the paint. The stains in fact, are due to the formation of sulphate of lead. In No. 49 they were found on the woodwork below and above. In No. 48 and 44 they were found chiefly on the woodwork of the front bedroom door, and they unequivocally prove that the sulphuretted hydrogen, as a gas, has been diffused at some period or other in the air of the upper and lower rooms. The house No. 16 was visited. The tiles in the floor were very damp. I was informed that it had been shut up, and not inhabited for some time. On entering there was the usual close offensive smell, perceived more or less in all the houses. The junctions of the tiles in the cement presented a remarkable yellow appearance. This was spread over from 4 to 6 square feet of the tiles, above the centre of the lower front room. A sample of this was collected and has since been analysed. It consists of sulphur, sulphuric acid, oxide of iron, and a small quantity of lime. This is the residue of the decomposition of iron-slag, under the influence of air and water, and after the sulphuretted hydrogen, one of the products of this chemical change, has escaped.
Analysis Of Slag From No. 49
The slag taken from the excavations made in the back and front rooms of 49 contained lime, allumina, carbonate of lime, and a large proportion of sulphide, or what is termed sulphate of iron. There was no sulphide of calcium present.
The Slag Heap
I at the same time inspected the large accumulation of slag collected at the back of the houses. Samples were taken at various points, some from the surface, and others at from one foot to three or more deep. Samples were also taken from the part farthest from the houses, as well as from the part near to them. They all presented much the same composition, and all yielded an abundance of the sulphide or sulphurate of iron. Some portions that were near the surface yielded a large quantity of hydrosulphate of lime. Others from below the surface yielded sulphide of calcium. At a distance of 57 feet from the house No. 49 a hole had been dug to the depth of about three feet, and from this torrents of hot vapour, charged with a large quantity of sulphuretted hydrogen, was at the time issuing. Other parts, when penetrated, also yielded vapour, showing that there was great heat in the mass below. In some parts towards the edge of the bank of slag, it was at a full red heat. About a foot below the surface sulphur had sublimed the fissures of the surface of the heap, resembling the appearance seen in the crater of a volcano. The vapour produced by combustion consisted of aqueous, vapour charged with sulphuric acid.
I may observe that the slag taken from the house No. 49, as well as that from the heap was tested for arsenic, but there was no trace of that poison present in either sample. The slagheap is close to the back wall of the houses numbered from 44 to 49. It is above the level of the back yard in each of these houses, and at the house No. 49 I estimated that it rose at no great distance to a height of from two to three feet above the level of the back yard; hence it follows that any large amount of rain falling on the slag heap will penetrate through the porous slag and find its way under the floors of the houses, chiefly from No. 49 to 46. To a certain extent this would also happen with respect to the house No. 45 and 44, but the slagheap here slopes rapidly in a westerly direction, so that a portion of the rainfall will pass out at the rear without going under the foundations. I caused the foundation of the back wall of the house No. 49 to be laid bare, and saw the bottom of it. The wall extended but a very few inches below the surface of the slag, properly not more than five inches. I found that there was a complete and free communication from the slag of the heap under the back wall to below the whole of the floor of the back and front rooms of the house, so that any large amount of water falling on this heap would find its way in part under the foundations of this and adjoining houses.
The rain discharged from the roof falls on broken surface of the soil, and penetrate into the slag beneath.
The road in front of the houses is raised in the centre so that on one side there is a tendency of the overflow to find its way to the front of the houses.
On Tuesday, June 23rd, 1857 I attended the adjourned inquest held in this place on the bodies of six persons, into the cause of whose death we are met to inquire. The depositions of all the witnesses previously taken were read in my presence. The evidence of other witnesses were taken, and by the courtesy of Mr. Lumb, the coroner, such other questions were put as appeared necessary to the formation of an opinion of the cause of death in these cases.
Applying my mind to the evidence thus adduced, to the inspection of the houses, and the locality where these deaths occurred and aided by experiments which I have been enabled to perform, I have come to the conclusion already arrived at by the medical gentlemen who have given their evidence at this inquest, viz.,
1st. That the six persons deceased, into the cause of whose death we are inquiring, did not die from any natural or unusual form of disease, but that they died from the effects of gaseous poisoning; and my opinion is that the noxious agent was sulphuretted hydrogen.
This gas did not emanate from the iron furnaces, nor from the surface of the slag heap directly; but it proceed from the rainfall (about the period of the calamity) penetrating the heap and washing the sulphuretted hydrogen beneath the foundations of the houses, at the back of which it is piled. Further the contact of water with the sulphide of iron contained in the slag produces this poisonous gas, so that the rainwater already containing sulphuretted hydrogen, produced by contact with the iron slag beneath the houses, a larger amount of this gas would find its way through every crevice or porous material. Thus, then, the action of water on the iron slag is, in my opinion, the cause of the production of this gas. It is going on at all times, in a ratio proportioned to the undercomposed sulphide of iron present, and the quantity of water which finds its access to the foundation. When once there, there is no escape for the gas but through the floor and the whole of the house. Its evolution at the period of the calamity was greater by reason of the heavy rain preceding the occurrence, and the heated state of the atmosphere.
It has been given in evidence that the slag laid beneath the floor of the houses was taken fresh from the iron works when the houses were built, about six months since. As it had not been exposed to the air sufficiently long to decompose the sulphide of iron, it was therefore used in a state most calculated, under a copious supply of water, to produce sulphuretted hydrogen in the largest amount.
That this was the source of the gas, which caused death, appears to me to be proved.
1st. By the discovery of the gas in large quantities, evolved with steam, at a depth of two or three feet below the slagheap.
2nd. By the discovery of the gas actually evolved when the floor was raised on Monday last in the house 49.
3rd. By the presence of such a substance as sulphide of iron in large quantities from the slag of the foundation of the houses as well as from the heap.
4th That there was no other source for its production if we except the presence of sulphide of calcium in the slag heap, which would considerably add to the augment the danger arising from heavy rain falling on the heap. This arises from the fact that sulphide of calcium is instantly and completely decomposed by water, while sulphide of iron is more slowly decomposed.
That the deadly poisonous gas was evolved beneath the floors and penetrated the house, accumulating in those places where there was the least ventilation and no current of air, is provided.
1st. By the discovery of it in the porous soil beneath the floor.
2nd. By its action on patches of paint in the lower room.
3rd. By the discovery on the floor of a damp house, No. 16, which had not been disturbed for some time, of the oxide of iron sulphur, and sulphuric acid.
This material is the result of the decomposition of sulphide of iron in the slag under exposure to air and moisture. It is the solid part of the decomposed slag, while the sulphuretted hydrogen is the gaseous part.
That this gas was the cause of death is proved by the symptoms and appearances taken as a whole. They are similar to, but more severe and fatal, than those, which I witnessed in 1839 in men working at the tunnel under the Thames (Medical Jurisprudence, 5th edition, 791 pp.) The sulphuretted hydrogen was produced by the action of water trickling through the soil on sulphide of iron contained in the soil.
In conclusion, I beg to make this general observation. Every house built on this fresh iron slag is exposed to dangerous accidents of this kind according to the access of water beneath the foundation. The quantity of fresh slag present beneath the foundation, the porousucess or imperfection of the floor, and general want of ventilation in the closets or chambers, having no current or air through there, becoming boxes for the reception and circulation of this poison, and the four houses from No. 49 to 46 are so situated, with respect to the slag heap as to the house of death to all who inhabit them with the doors and windows closed, and under heavy rain falls. None can inhabit them without injury to health, if not danger to life. This danger will exist in all the houses more or less, until the slagheap is entirely decomposed. The houses 49 and 48 will always be dangerous so long as the washing of the slagheap can find their way beneath the foundations.
Alfred Swaine Taylor, M.D, F.R.S
Lecturer on Medical Jurisprudence and Chemistry, Guy's Hospital
The Professor having enlarged, viva voce, on some of the opinions expressed in his report, corroboratively bearing out those opinions, and answered the inquiries of certain of the jury.
The Coroner announced that the case for the Crown was closed, and wished to know of Mr. Postlethwaite whether he proposed to call witnesses.
Mr. Postlethwaite answering negatively.
The Coroner charged the jury at great length, remarking that from the first hearing of the case his opinion had been similar to that entertained by Dr. Bateman Wilson, who was the only medical practitioner who had gone so far as to give a decided opinion as to the cause of death, and which opinion Dr. Taylor had unequivocally confirmed. The Coroner concluded by passing encomiums on various gentlemen, including the jury, whose time and services had been engaged upon no fewer than five occasions during the inquiry.
The jury retired, and after about half-an-hour's deliberation, returned into court with the following.
Verdict
"We find that Joseph Armstrong, the elder, Mary Armstrong, Robert Armstrong, Joseph Armstrong, the younger, John Sloane, and Fenton Murray, have come to their deaths accidentally, and that the cause of death in all these cases has arisen from the inhalation of sulphuretted hydrogen gas, generated from the slag underneath the houses in which they dwelt, and from adjoining heap of the same material.
"W. B. Clarke, Foreman."
In returning the above verdict, the jury recommend that the houses at Bowthorn-row, built upon the slag from the Hematite Works, should be efficiently drained, and all communication with the adjoining slag heap, through the foundations of the houses, be effectively cut off; and the jury are further of opinion that the houses so circumstanced cannot be safely occupied till this is done.
Top Photo: Bowthorn Road, C1900
