The Sheffield Iris dated Tuesday 19 November 1839 had quickly recognised the threat that substances such as Godfrey’s Cordial represented. In a column which discussed ‘Deaths in England by Poisoning’ the reporter listed 10 children’s deaths that had taken place that year alone in Sheffield. Many of these had been from overdoses innocently administered by mothers. It noted that the residue of such poisons soon disappeared in the child’s stomach, so it remained undetectable to surgeons completing post mortems. As a result, Coroners often ruled many of the mysterious deaths of young children as accidental. One such example of this was noted on Tuesday 11 July 1843 at an inquest on a boy aged just three years old.
He was William Henry Blake whose parents lived in Trafalgar Street, Sheffield where a verdict of ‘died by visitation of God’ was given. This was a catch-all verdict which basically meant that the jury did not know why the person had died. Nevertheless it was noted that ‘some suspicion had been excited that the child had been poisoned, but no proof of this was adduced, though the mother was in the habit of giving him large quantities of Godfrey’s Cordial.’ Another child’s death which was remarkable similar took place twelve years later, and it was also blamed on the same source. On Saturday 12 May 1855 an inquest on a four week old baby, took place at the Plumpers Inn, Duke Street, Park, Sheffield. He was the son of a woman called Milnes, and the Coroner Mr Badger called the child’s unnamed grandmother as the first witness.
She described how she had taken him with her when she had been washing at the house of a woman called Mrs Pickering. Upon hearing the child crying, the witnesses employer gave him half a teaspoon of some Godfrey’s Cordial to keep him quiet. The grandmother told the inquest that the baby almost immediately fell asleep, and that she had been thankful as she was now able to continue with the washing. Only when the child awoke a while later and started to convulse, did the witness become concerned. The poor woman cried as she described her grandson dying in her arms soon afterwards. A surgeon Mr Lawton told the Coroner that he had been called out to see the baby, even though it was already dead by the time he arrived. He stated that death was caused by convulsions after the administration of a narcotic poison.
The next witness at the inquest was Mr John Henry Dixon Jenkinson of Duke Street, a druggist who admitted to selling the cordial and gave a list of its contents. These consisted of a mixture of opium, sassafras, treacle and water. The druggist told the jury that he had been horrified when he heard how much the child had been given. He pointed out that clearly printed on the label attached to the bottle was a statement that only ten drops should be given to a baby four weeks of age. Then the woman who had administered the cordial, Mrs Pickering was brought into the room. She was castigated by the Coroner for having administered such a large dose to the little boy. Mr Badger roundly condemned the use of such ‘noxious compounds in any quantity to a child of that age.’ The jury had no option but to return a verdict that ‘the child had been inadvertently poisoned by Godfrey’s Cordial by mistake.’
Government legislation of 1857 tried to restrict such compounds being sold over the counter, but it failed to get passed through Parliament. Consequently six years later that ‘blessing to parents’ was still killing children. Evidence was heard again at an inquest held in the afternoon of Tuesday 17 February 1863 in the vestry room of the Congregational Chapel on Occupation Road, Sheffield. The Coroner Mr J Webster Esq., told the jury that the inquest had been called to enquire into the death of a ten day old male child, the son of a labourer called William Hides of Hallcar Street, Sheffield. The child’s mother, Mary Hides was the first witness and she told the jury that her son had been born on 7 February 1863.
She said that since his birth he had shown slight convulsions and on the previous Saturday had developed thrush. About 7 pm he would not settle and so she gave him some rum on a teaspoon, which not surprisingly, caused him to promptly vomit. Desperate at this point, she then gave the baby three drops of Godfrey’s Cordial, and soon afterwards the child became insensible, before dying the following day. After hearing all the evidence, the jury returned a verdict that ‘the deceased died from poison administered by its mother, but without any felonious intent’.Sadly no lessons were learned and parents continued to administer this deadly medicine to their children. It was just a month later when the next death of yet another Sheffield child to be given this deadly opiate, occurred.
On Friday 20 March 1863, a mother called Ann Dodd of Bernard Street, Park, Sheffield gave her nine month old son half a teaspoon of Godfrey’s Cordial. The next morning she was horrified to find little William dead in his cot. Once again an inquest was held the following day by Mr Webster at the Union Inn on Duke Street, Park. To the jury’s concern Mrs Dodd freely admitted that not only had she given her son some Godfrey’s Cordial on the night he had died, but she had been in the habit of giving him the same amount on a regular basis in order to build up his constitution. In fact she claimed that she had given him the cordial every night for the last three months. The verdict was given that ‘the deceased died from poison, having had administered to him for ninety consecutive days, a mixture called Godfrey’s Cordial.’
Nevertheless Godfrey’s Cordial continued to be sold freely to the desperate parents of Sheffield. It was still on sale a year later when yet another child’s death was recorded. However this one was felt to be more suspicious, as it had been administered to an illegitimate baby. Any kind of illegitimate birth resulted in both the mother and child being condemned by society, so there was strong suspicion that the mother might have given the child the cordial to rid herself of the shame. To emphasis this undercurrent of suspicion, it was established that the mother had been alone at the time she gave the child some Godfrey’s Cordial.
The inquest opened at the Town Hall by deputy Coroner Mr W W Woodhead Esq., who was told that the two week old little boy had been suffering from a bowel complaint before his death. On the night of Monday 21 March 1864 his mother Mary Ann Eams admitted that she had given him some Godfrey’s Cordial at the house she lived on Water Lane Sheffield. She told the jury that she only gave him three drops, but he grew gradually worse and died around 5 am on the following morning. Once again the verdict named the substance which had caused the child’s demise. It was recorded to be a death from an overdose of Godfrey’s Cordial. If the Sheffield Coroners had hoped to underline the dangers of parents giving their children such a deadly poison, it had not worked.
By November of the same year, so many deaths of young children from that and other similar substances had been recorded in the town, that they now took up very little room in local newspaper columns. One such report in the Sheffield Independent dated Saturday 12 November 1864 simply recorded:
‘On Wednesday morning, the death of a child aged seven weeks was caused by its mother, Mrs White, a widow residing in Eckington. She administered a dose of Godfrey’s Cordial on the previous night about 11pm, the child being restless. It lingered until about 11 am of the morning following. Mr Jones surgeon was called in, but not until after the death.’
In fact on this occasion more column space was given to the article which followed, which was about picking pockets at Masbrough Station in Rotherham. Concerned about the numbers of deaths brought about by laudanum and other opioids, the Government brought in the Pharmacy Act of 1868. This established that only qualified and registered chemists could now sell such opium derivatives. However Godfrey’s Cordial was exempt, as it was described as a patent medicine. This encouraged desperate parents to continue to buy the cordial and consequently children’s death’s continued to happen.
The next time Godfrey’s Cordial was heard of in Sheffield however, it took on much more serious police enquiry. This was not just a case of overdose by a distracted parent, but led to the charge of manslaughter by a registered chemist. It involved the man called John Henry Dixon Jenkinson who had served Godfrey’s Cordial to the baby Milnes fourteen years earlier. It seems that after the child’s death he had sold the druggist business to his brother and left Sheffield continuing as a druggist elsewhere. In the middle of July 1869, he had been invited by his brother to come back to Sheffield, in order to look after the shop in Duke Street for a week in his absence.
On the night of 14 July 1869 a three month old child called Walter Nutton was becoming very restless and disturbed at the house of his parents on St John’s Place, Sheffield. He was the youngest of four children born to his mother Maria, and on that night she was having difficulty in getting him to sleep. She was used to giving little Walter regular doses of Godfrey’s Cordial and as a result she had run out, so she sent her 13 year old sister Mary Ann Holland for a penny worth of the cordial from the Jenkinson’s shop. When the girl returned, Maria gave her son half a teaspoonful and Walter immediately went into convulsions. In a panic Maria sent her sister back to the shop to inform Mr Jenkinson. To his horror, he found that he had given the girl laudanum by mistake. This was an opium based product for adults.
Upon hearing of the dangerous condition of the child, he immediately urged the girl to call out a surgeon. Maria sent her sister to Mr Thomas’s surgery nearby and he arrived at the house around 8 pm. He did what he could for the baby, but little Walter died the following morning at 7 am. An inquest was held on Saturday 17 July at the Green Man Hotel on Broad Street, Park, Sheffield by the Coroner Mr J Webster Esq. The surgeon Mr Thomas was the first witness and he stated that he had been called to the house on the evening of Wednesday 14 July where he found a child looked undernourished and thin. He said that the child was in a coma and the pupils of his eyes were contracted. The surgeon stated that all the symptoms indicated to him that the child had been poisoned by laudanum.
Mr Thomas told the jury that he used what remedies he could to make the child vomit, but it had all been in vain. He added that he thought it very unwise of the mother to have given her children Godfrey’s Cordial on a daily basis. The father of the deceased child was the next witness and he told the inquest that his name was Charles Nutton and he was an edge tool striker by trade. He confirmed the fact that his son had been delicate from birth and his wife was anxious to make him stronger, so she was innocently in the habit of giving Walter some Godfrey’s Cordial on a regular basis to build him up. The next witness was his wife Maria who was unfairly challenged by the Coroner for giving her child something, which she thought would make him stronger.
She told the Coroner that her son had been just eleven weeks old before she described the circumstances of sending her sister for some cordial and how she had given the mixture to her son. Maria told Mr Webster that she understood that Godfrey’s Cordial was good for all her children as it was advertised that it would ‘nourish their insides.’ Therefore she gave him and her other children one dose every day. The Coroner retorted ‘by giving your child so much of the cordial every day since it was born, you have done your best to kill it.’ When the poor distraught mother told him that she had done the same for her five year old son, Mr Webster unfeelingly told her ‘I wonder it has not killed him also then.’
The Coroner asked her if she had noticed anything different in what she took to be the cordial, but Maria told him that it just looked the same to her. However after the child had died, she put some onto a teaspoon and tasted it and it seemed to be ‘too strong.’ That was when she realised that it was not the usual cordial. After hearing the evidence of the two parents, Mr Webster adjourned the inquest to the following Monday in order to request the presence of the druggist concerned to give evidence of how laudanum was given to the child by mistake. When the inquest was re-convened, Mr John Jenkinson was present and he listened carefully as the first witness Mary Ann Holland gave her evidence of buying the Godfrey’s Cordial from his brother’s shop.
At his own request Mr Jenkinson was then sworn in to give his defence. Right from the start he freely admitted that the mistake had been his. He said that it was only when Mrs Nutton’s sister brought the bottle back, did he realise what had happened. In order to prevent further accidents he substituted the remains of the laudanum for Godfrey’s Cordial and returned the bottle back to the girl. When the Coroner made some remark about it all being too late, Mr Jenkinson told him that he took every precaution to prevent mistakes, but they sometimes happened regardless. He admitted that the bottle which had contained the laudanum had been placed on the shelf next to the Godfrey’s Cordial. However since the accident, he had made sure that they were both kept completely separate.
At this point Mr Webster condemned the sale of any substance which included opium for infants as he told the people at the inquest:
‘As a public officer I feel bound to say that it is a very dangerous practice indeed for druggists or for anyone except regular practitioners to sell any preparations of opium to be given to infants, especially when they are so small that a quantity was sufficient to destroy life. It is a practice that could not be too strongly reprobated by these gentlemen at the inquest. It is a very serious thing, as the number of children who lost their lives by opium was very large indeed.’
Then Mr Jenkinson dropped a bombshell. He admitted that the Godfrey’s Cordial he had given the girl was not the well known product that had been advertised, but was instead a variation of his own making. He described how he had used the same ingredients as the original cordial and made them up himself. After hearing this, the Coroner summed up for the jury. He told them that:
‘You will have to consider whether it was carelessness or the neglect of Mr Jenkinson which caused the child’s death. If you think that Mr Jenkinson had not taken due care before dispensing the mixture, then you will be bound to find him guilty of manslaughter.’
He concluded his summing up by informing the inquest that this was the second case he had in the last few days alone. The jury considered the case for just 30 minutes before returning back into the inquest room. There the foreman gave the verdict that ‘John Henry Dixon Jenkinson of Sheffield did feloniously and unlawfully kill and slay Walter Nutton.’ However he added that:
‘There has been a good deal of discussion about this matter, and the whole fourteen jurymen have agreed that we cannot return any other verdict but manslaughter. We are however, so pleased with the young man’s statement – not withstanding his gross carelessness – that we strongly recommend him to mercy.’
John Jenkinson was then placed in the custody of a constable who took him directly to the Town Hall where he was bailed on sureties of £100 for himself and two other sureties of £50 each.
John Henry Dixon Jenkinson was brought before judge Mr Baron Cleasby on Thursday 5 August at the Leeds Assizes charged with the manslaughter of Walter Nutton on 14 July 1869. The prosecution, Mr Barker outlined the case for the Grand Jury and stated that the mother of the child was in the habit of giving him Godfrey’s Cordial on a daily basis. He outlined the case before stating that at the inquest the prisoner had readily admitted his mistake, although he could not account for how it had occurred. However he said it was for the jury to say whether or not the prisoner ought to be held criminally responsible for his actions.
Jenkinson’s defence Mr Waddy told the court that he had studied the case and stated that rather than manslaughter, his client was simply guilty of gross negligence. The shop belonged to the prisoners brother and therefore he was not used to the layout of the drugs he sold. He stated that because the prisoner was not used to it, he had made a simple mistake in the bottles which were possibly in a different place to those he was used to. Mr Waddy also added that according to the evidence, the mother of the child had given her son more than the prescribed dose, and that therefore she was as culpable as the prisoner. He said that if the medicine had been administered by mistake, then the verdict could only be one of homicide by misadventure.
The defence counsel concluded that therefore it was a genuine mistake which no one regretted more than the prisoner himself. He had several times expressed great remorse for the child’s death which he admitted had been caused by his own negligence. The next witness was a chemist from Birmingham called Mr J J Hughes who told the jury that he had employed the prisoner for the last nine months. He said that during the time he had worked for him, he had taken unusual care in the discharge of all his duties. The judge, in his summing up, addressed the jury and stated that:
‘A man ought not to be convicted for manslaughter for a mistake which even the most careful were liable to fall into. You should consider whether there was, on the part of the prisoner, any criminal neglect as to make him responsible and guilty of the crime of which he stood charged.’
He added that he thought the charge should never have been brought before the assizes. The jury agreed and the prisoner, to his great relief was acquitted.
Nevertheless Godfrey’s Cordial continued to be sold to desperate parents anxious to give their children a remedy which would either build up their constitutions, or soothe their restlessness. However such bad publicity about the cordial empowered other courts throughout Britain to encourage parents to use much safer products. Only then did the use of Godfrey’s Cordial begin to dwindle. Finally the Pharmacy Act of 1908 was passed, which restricted the use of all opium based drugs including Godfrey’s Cordial. Only then finally did the sales of this ‘blessing to parents’ gradually decline.