Chapter I: Part 1

[Picture: Public domain book cover]

OBSERVATIONS
ON
CORONERS,

BY

WILLIAM HEWITT, SURGEON,
NORTH WALSHAM,

Author of an Essay on the Encroachments of the German
Ocean, with a design to arrest its further depredations.

* * * * *

“_Unius ætatis sunt quæ fortiter flunt_, _quæ_
_pro utilitate scribuntur æterna_.”

* * * * *

PRINTED FOR THE AUTHOR,
BY SAMUEL DAYNES, SAINT STEPHEN’S STREET, NORWICH;
SOLD BY JOHN CHURCHILL, MEDICAL BOOKSELLER, PRINCES’ ST.,
SOHO, LONDON;
OURY AND CO., LONDON ST., NORWICH;
JOHN MOWER, NORTH WALSHAM, AND ALL BOOKSELLERS.

Entered at Stationers’ Hall.

* * * * *

_To the Right Honourable The Secretary of State_, _for the Home Department_.

SIR,

The importance of the subject, I humbly anticipate will be sufficient excuse for the liberty I have taken, in dedicating to you the result of my experience connected with Coroners’ Inquests.

The instances narrated with reference to apparent delinquencies, in non-medical Coroners, contained in the following pages, occurred in my immediate neighbourhood, and may be believed, as resting on the brow of truth. Yet I most heartily coincide in acknowledging the integrity and worth, of Gentlemen pursuing vocations, for which they have alone been amply educated; and it is only when they assume a position, or accept office to execute duties they are incompetent to perform, as is frequently observed, that I deem it my duty to wield my pen against such appointments: not less for the sake of humanity, than for the dignity, and I might add, the disregarded importance of the medical profession, to which I have the honor to belong.

I am, Sir,

Your very humble and obedient Servant,
The AUTHOR.

OBSERVATIONS ON CORONERS.

“If there’s a hole in a’your coats,
I rede you tent it:
A Chield’s amang you, taking notes,
And, faith, he’ll prent it.”

IT is no inglorious vanity in Englishmen to consider the laws of their country afford an example for other nations to follow. Founded on the lasting rock of integrity, shewn in the strict regard for the liberty of the subject, they command the obedience and the admiration of thousands. But events, as they transpire, unfold the humiliating circumstance, that blemishes dimly seen in the distance become prominent on the near approach of extending knowledge; thus disclosing the fact, that this is a progressionary as well as a probationary world in which we live, and that perfection in human institutions cannot be attained, unless, through the power of an Infinite Being, the mortal in his earthly career be permitted to assume immortality.

Trial by jury appears the great feature by which the laws are regarded; and a better test for its usefulness cannot be pourtrayed than when with becoming dignity, discrimination, and foresight, it is employed to search into the cause of the death of a fellow creature; consequently no judge in the lands hold a higher position than a coroner, for almost unlimited power is allowed, perfectly in accordance with the sacred trust imposed upon him. But the responsibility attached to office, involves duties of extraordinary character; and the public have a right to expect that efficient pains-taking persons should be appointed, so that enquiries should be conducted in a clear, straightforward, impartial, manner; otherwise innocence might be tarnished, criminals might escape, and laws—coeval with life, framed for its protection—might be considered non-entities.

Coroners are officers at common law, because they deal principally with the pleas of the crown; and, possibly, the name may be derived from the manner of holding the inquest in _corona popupuli_. The Lord Chief Justice of the Queen’s Bench is, by virtue of his office, principal coroner of England; and may, if he pleases, exercise the jurisdiction of coroner in any part of the realm. In former days they were the principal conservators, and principal magistrates, within their counties, and they may now bind to the peace any person who make an affray in their presence.

The office of Coroner is of great antiquity, for in the days of Alfred, King of England, they existed, for he punished with death, a judge who sentenced a party to suffer death upon the coroner’s record, without allowing the culprit to traverse or be tried in another court. Coroners were ordinarily made by grant or commission, without election—such are the coroners of particular lords of liberties or franchises, who by charter, have power to create their own coroners, or to be coroners themselves. Thus, the Lord Mayor of London, is by charter of 18 Edward the Fourth, Coroner of London. The Bishop of Ely also has power to make coroners in the Isle of Ely, by charter of Henry the Seventh—Queen Catherine had the hundred of Colridge granted her by Henry the Eighth, with power to nominate coroners.

The Cinque Ports {7} have their own coroner. The Dean and Chapter of Westminster have their own coroner, who by their appointment, is coroner of the city and liberties of Westminster. The Wardens are coroners of the Stannaries in Cornwall. The Master of the Crown Office, or Clerk of the Crown, is Coroner of the Queen’s Bench, and has jurisdiction over matters arising within the prison of that court and Marshalsea. He holds his office by letters patent, under the great seal. In addition to which, there are many exclusive jurisdictions and corporations, for which coroners are appointed.

In each of the twelve shires, in Wales, and Cheshire, &c. there are only two coroners, which are settled by stat. 33 H. 8, c. 13 and 34 H. 8, c. 26.

But the two principal jurisdictions over which by the King’s grant, coroners may be appointed, are those of the Admiralty and the Verge.

At common law, if any felonies or treasons were committed within any creek or arm of the sea, which was in the body of the county, the common law courts had jurisdiction; but by stat. 15 Richard 2, c. 3, it was provided, that in “case of the death of a man or mayhem, done on great ships hovering in the main stream of great rivers only beneath bridges nigh to the sea, the admiral shall have cognizance of the same rivers.”

It is said that his jurisdiction extends only to rivers that are arms of the sea, namely, that flow and re-flow, and bear great ships. When the haven, &c. is within the body of the county, the common law tribunals have a concurrent jurisdiction, and the Coroner of the County as well as of the Admiralty, may take inquisition of deaths, &c. happening there.

Therefore, when a man-of-war was _infra corpus comitatus_, the land coroner was holden to have jurisdiction; and if the captain refuse the coroner admission, on board, the court will grant an information.

Again the Admiralty jurisdiction extends only to such deaths, &c. as happen in great ships, and not to such as occur in small vessels.

When the jurisdiction of the County and of the Admiralty is concurrent, the coroner who first seizes the body, is entitled to take the inquisition; and if he proceed to do so, the authority of the other is determined.

The other great jurisdiction is the Coroner of the King’s House, usually called the Coroner of the Verge, who it seems anciently was appointed by the King’s letters patent, but by stat. 33 H. 8 c. 12, the granting thereof, is settled in perpetuity in the Lord Steward, or Lord Great Master of the King’s house for the time being.

Anciently the Coroner of the Verge had power to do all things within the Verge belonging to the office of the Coroner, to the exclusion of the Coroner of the County; but because the King’s Court was often moveable, it is ordained by stat. of Articuli super Cartas, c. 3, that on the death of a man, the Coroner of the County shall join in inquisition, to be taken thereof, with the Coroner of the King’s house, and if it happen it cannot be determined before the Steward, process and proceedings shall be thereupon had at common law.

But yet in the case of death within the Verge, the Coroner of the County cannot take an inquisition without the Coroner of the Verge; and if he does it is void, but if one person be Coroner of the County, and also of the Verge, the inquisition before him is as good as if the offices had been in several persons and taken by both. And though the court remove, yet he may proceed upon that inquisition as Coroner of the County.

Beside those above enumerated, there are particular coroners for each county, who hold their offices (virtuta electionis) in pursuance of the statute 3 Edward I. c. 10, wherein it is provided, that “through all shires sufficient men shall be chosen to be Coroners, of the most loyal and wise knights,” which _know well_ and _may best_ attend upon such offices, and “which lawfully and shall attend and present pleas of the crown.” Therefore the election of a coroner, is by the freeholders of the county, in pursuance of a writ, called a writ _De coronatore eligendo_, directed to the Sheriff.

This statute does not define the precise number which varies in different counties, according to usuage. In some there is only one—in others, there are two, four, and six coroners appointed. But as no number is limited by the statute, it is competent for the Lord Chancellor if he thinks fit, to issue a writ for the election of one or more additional coroners, upon the petition of the freeholders of a county, and the approbation of the justices, certified at the general quarter sessions of the peace, holden for the county.

The degree of knighthood, observes “Sewell on the Law of Coroners,” is now no longer an essential qualification for the office of coroner. Yet candidates for that office must it is said, have land sufficient to take upon themselves that degree, whether they be really knighted or not. They must be possessed of an estate in fee, within the county, over which, if elected, their jurisdiction will extend. The statute 14 Edward 3, s. 1 c. 8, enacts, “that no coroner be chosen, unless he have land in fee sufficient in the same county whereof he may answer to all manner of people.” No precise amount of estate is defined by this statute, but the coroner ought to have sufficient property to maintain the dignity of his office, and to answer any fine that may be set upon him for his behaviour. But if having an estate in fee within the county, it be insufficient to answer his fines, that will not operate as a disqualification or be a ground for his removal, if he be of sufficient estate to execute his office, for the county, upon his default, will be liable to the fine as punishment for having elected an insufficient officer.

The authority of the coroner is twofold:—

1. Judicial

2. Ministerial

In his judicial capacity, he has to enquire when any one comes to his death suddenly or violently; how and by what means such death was caused; to pronounce judgement upon out-lawries; to inquire of lands and goods, and escapes of murderers, treasure trove, wreck of the sea, deodands, &c.

Before the statute of Magna Charta, c. 17, (4,) coroners held pleas of the crown, but that power is taken away by a more recent enactment. The Sheriff in his tourne might by the common law, inquire of all felonies, save the death of a man, but it is doubtful whether the coroner can inquire of any felony but the death of a person, and that _super visum corporis_, except in Northumberland, where the coroner may, by custom, inquire of other felonies.

In his ministerial capacity, he has to execute the King’s writs, when the Sheriff is a party to the suit, or kin to either of the parties, or on default of the Sheriff, but they are only authorized so to act in the execution of a process directed to them when their acts are void, unless they all join.

Coroners are conservators of the King’s peace, and become magistrates by virtue of their election and appointment. This privilege, independently of their more official duties, they are entitled at this day to exercise; and are empowered to cause felons to be apprehended, as well as those that have been found guilty after inquisition, as those suspected of guilt, or present at the death, and not guilty; as also burglers and robbers, in respect of whom, no inquisition can be taken. And this, says Lord Hale, appears evidently by the statutes, 3 Edward I, c. 94, and 4 Edward I. _Officium Coronatoris_, and with this agrees the common usage at this day; for many times the inquest are long in the inquiry, and the offender may escape, if the coroner stay until the inquisition is delivered up.

Where coroners are empowered to act as judges, as in taking an inquisition of death, the act of one of them is of the same force as if they had all joined.

The office of Coroner being by election, does not determine by the demise of the king.

The jurisdiction of coroners is limited to the county, liberty, or precinct, to and for which they are elected and appointed, and cannot be enlarged by any private act or delegation from the crown.

By the common law, if a man had been stricken in one county, and died in another, it was doubtful whether he were indictable or liable in either; but the more common opinion was, that he might be indicted where the stroke was given. And if the party died in another county, the body was removed into the county where the stroke was given, for the coroner to take an inquisition _semper visum corporis_.

But the statute 2 and 3 Edward the Sixth, cap. 24, sec. 2, provided that when any person shall be feloniously stricten or poisoned in one county, and die of the same stroke, or poisoning in another county, an indictment thereof found by jurors of the county where the death shall happen, whether before the coroner upon the sight of such dead body, or before the Justices of the Peace, or other Justices or Commissioners, which shall have authority to inquire of such offences, shall be as good and effectual in the law, as if the stroke and poisoning had been committed and done in the same county where the party shall die, or where such indictment shall be founded. This statute, however, assumed the existence of a _felony_, and was silent entirely as to what is to be done by the coroner or jury if no such indictment were found. The effect of any other finding was left entirely as it stood at common law.

It was thought, too, that the statute 2nd and 3rd Edward the Sixth, cap. 24, did not extend to boroughs; but that in cases of felonious killing, where the stroke, occurred out of the borough, and the death, within, the jurisdiction of the coroner, was according to common law.

By the 9th George the Fourth, cap. 31, sec. 8, it was enacted, that, “where any person being feloniously stricken, poisoned, or otherwise hurt upon the sea, or at any place out of England, should die of such stroke, poisoning, or hurt in England, or being feloniously stricken, poisoned or otherwise hurt at any place in England, should die of such stroke, poisoning, or hurt upon the sea, or at any place out of England, every offence committed in respect of any such case, whether the same amounted to the offence of murder or of manslaughter, or of being accessory before the fact to murder, or after the fact to murder or manslaughter might be dealt with, enquired of, tried, determined, or punished in the county or place in England, in which such death, stroke, poisoning, or hurt should happen, in the same manner, in all respects, as if such offence had been wholly committed in that county or place.”

By the 7th George the Fourth, cap. 64, sec. 12, it was enacted, “where a felony or misdemeanour is committed on the boundary of two or more counties, or within the distance of 500 yards of the boundary, or is begun in one county and completed in another, every such felony, &c. may be dealt with, inquired of, tried, determined, and punished in any of the said counties, in the same manner as if it had been wholly committed therein.” This enactment extends to the boundaries of counties only, and not to prosecutions in limited jurisdictions.

Many difficulties, however, having arisen on the construction of these statutes, as to the jurisdiction of coroner; by the 6 Vic. cap. 12, it was enacted, “That the coroner only within whose jurisdiction the body of any person upon whose death an inquest ought to be holden, shall be lying dead, shall hold the inquest, notwithstanding that the cause of death did not arise within the jurisdiction of such coroner; and in case of any body found dead in the sea, or any creek, river, or navigable canal within the flowing of the sea, where there shall be no deputy coroner for the jurisdiction of the Admiralty of England, the inquest shall be holden only by the coroner having jurisdiction in the place where the body shall be first brought to land.” And by sec. 2, it is further enacted, “That for the purpose of holding coroners’ inquests, every detached part of a county, riding, or division, shall be deemed to be within that county, riding or division, by which it is wholly surrounded, or where it is partly surrounded by two or more counties, ridings, or divisions, within that one with which it has the longest common boundary.” Sec. 3 provides for the trial of parties on verdicts of murder and manslaughter. Sec. 4, provides for the levying of deodands on verdicts.

The enquiry of the coroner must be restricted to the cause of the death of the person upon whom the inquest is taken, and cannot be extended to accessories after the fact. He may, however, inquire of accessories before the fact, for such are instrumental to the death. {17}

And by the statute 7 George the Fourth, c. 64, sec. 9, “the offence of the person counselling, procuring, or commanding, howsoever indicted, may be inquired of, tried, determined, and punished by any court which shall have jurisdiction to try the principal felon, in the same manner as if such offence had been committed at the same place as the principal felony, although such offence may have been committed either on the high seas, or at any place on land, within his majesty’s dominions or without. And in case the principal felony shall have been committed within the body of any county, and the offence of counselling, procuring, or commanding shall have been committed within the body of any other county, the last-mentioned offence may be inquired of, tried, determined and punished in either of such counties.”

This cursory glance of the office, the election, the authority, and the jurisdiction of coroners, show at once the importance of the trust imposed in them. Yet in the present day negligence and laxity prevail to such an extent, that a coroner’s tribunal is considered an inferior instead of a superior court, for some magistrates though differently elected, endeavour to control their labours, on the plea of economy—and this may be considered as one cause why coroners’ inquests appear unsatisfactory tribunals, for surely the doing so, must interfere with the sacred duties imposed and intended to operate on the minds of the many, that an untimely end of a fellow creature with all the awfulness attending it, should be carefully inquired into as the safety valve by which we live and move, and have our being.

The incomparable Dickens has, in one of the numbers of his present novel, “Bleak House,” sketched a lively representation of the manner in which these courts are commonly conducted; and as fiction demonstrates truthfully, truth itself, it may not be considered an unpardonable liberty in introducing the following extract:

The coroner frequents more public houses than any man alive. The
smell of sawdust, beer, tobacco smoke and spirits, is inseparable in
his vocation from death in its most awful shapes. He is conducted by
the beadle and the landlord to the Harmonic Meeting room, where he
puts his hat on the piano, and takes a Windsor chair at the head of a
long table, formed of several short tables put together, and
ornamented with glutinous rings in endless involutions, made by pots
and glasses. As many of the jury as can crowd together at the table
sit there. The rest get among the spittoons and pipes, or bear
against the piano. Over the coroner’s head is a small iron garland,
the pendant handle of a bell, which rather gives the Majesty of the
Court, the appearance of going to be hanged presently.

Call over and swear the jury!

“Well gentlemen,” the Coroner begins:—

“Silence there will you,” says the beadle—not the coroner, though it
might appear so. “Well gentlemen!” resumed the coroner, “you are
impanelled here, to enquire into the death of a certain man.
Evidence will be given before you, as to the circumstances attending
that death, and you will give your verdict according to the evidence
and not according to anything else. The first thing to be done is to
view the body.

“Make way there!” cries the beadle.

So they go out in loose procession, something after the manner of a
straggling funeral, and make inspection, from which a few of the
jurymen retire pale and precipitately.

The inquiry proceeds. The jury learn how the subject of the inquiry
died, and learn no more about him. “A very eminent solicitor is in
attendance, gentlemen,” says the coroner, “who I am informed was
accidentally present, when discovery of the death was made; but he
could only repeat the evidence you have already heard from the
surgeon, the landlord, &c., and it is not necessary to trouble him.”
Is any body in attendance who knows anything more?

Mrs. Piper pushed forward by Mrs. Perkins.

Mrs. Piper sworn.

Anastasia Piper, gentlemen, married woman.

Now, Mrs. Piper—what have you got to say about this?

Why Mrs. Piper has got a good deal to say, chiefly in parenthesis and
without punctuation, but not much to tell. Mrs. Piper lives in the
court, (which her husband is a cabinet maker,) and it has long been
well be known among the neighbours (counting from the day next but
one before the half-baptising of Alexander James Piper, aged eighteen
months and four days old, on account of not being expected to live,
such was the suffering of that child, gentlemen, in his genus) as the
Plaintive—so Mrs. Piper insists calling the deceased—was reported to
have sold himself. Thinks it was the Plaintive’s air in which that
report originatin. See the Plaintive often, and considered his air
was fearinocious, and not being allowed to go about, some children
being timid, (and if doubted, hoping Mrs. Perkins may be brought
forard, for she is here and will do credit to her husband, and
herself and family.) Has seen the Plaintive wexed and worrited by
the children, (for children they will ever be, and you cannot expect
them, specially if of playful dispositions to be Methoozellers which
you was not yourself.) On accounts of this and his dark looks, has
often dreamed as she see him take a pickaxe from his pocket and split
Johnny’s head, (which the child knows not fear, and has repetually
called after him close at his eels). Never however, see the
Plaintive take a pickaxe or any wepping far from it. Has seen him
hurry away when run or called after, as if not partial to children,
and never see him speak to neither child or grown up person at any
time, (except the boy that sweeps the crossing down the lane over the
way round the corner, which if he was here, would tell you that he
has been seen a speaking to him frequent.) Says the coroner, is that
boy here? Says the beadle no, sir, he is not here. Says the
coroner, go and fetch him then.

Oh! Here’s the boy, gentlemen!

Here he is, very muddy, very hoarse, very ragged. Now boy!

But stop a minute. Caution. This boy must be put through a few
preliminary paces.

Name, Jo. Nothing else that be knows on. Don’t know that everybody
has two names. Never heerd of sich a think. Don’t know that Jo is
short for a longer name. Thinks it long enough for _him_. _He_
don’t find no fault with it. No lather, no mother, no friends.
Never been to school. What’s home? Knows a broom’s a broom, and
knows its wicked to tell a lie. Don’t recollect who told him about
the broom, or about the lie, but he knows both. Can’t exactly say
what’ll be done to him arter he’s dead if he tells a lie to the
gentlemen here, but believes it’ll be something wery bad to punish
him, and serve him right—and so he’ll tell the truth.

“This won’t do, gentlemen” says the coroner, with a melancholy shake
of the head.

“Don’t you think you can receive his evidence, sir,” asks an
attentive juryman.

“Out of the question,” says the coroner, “you have heard the boy.”
‘Can’t exactly say’ won’t do you know. We can’t take _that_ in a
Court of Justice, gentlemen. It’s terrible depravity. Put the boy
aside.

Now. Is there any other witness? No other witness.

Very well, gentlemen! Here a man unknown proved to have been in the
habit of taking opium in large quantities for a year and a half,
found dead of two much opium. If you think you have any evidence to
lead you to the conclusion that he committed suicide, you will come
to that conclusion. If you think it is a case of accidental death,
you will find a verdict accordingly.

Verdict accordingly. Accidental death. No doubt. Gentlemen, you
are discharged. Good afternoon.

While the coroner buttons his great coat, the eminent solicitor, and
himself, give private audience to the rejected witness in a corner.

That graceless creature only knows, that the dead man (whom he
recognised just now by his yellow face and black hair) was sometimes
hooted and pursued about the streets. That one cold winter night,
when he, the boy, was shivering in a door-way near his crossing, the
man turned to look at him, and came back, and, having questioned and
found that he had not a friend in the world, said, “Neither have
I—not one!” and gave him the price of a supper and night’s lodging.
That the man had often spoken to him since; and asked him whether he
slept sound at night, and how he bore cold and hunger, and whether he
ever wished to die, and similar strange questions. That when the man
had no money, he would say in passing, “I’m am as poor as you to-day,
Jo,” but that when he had any, he had always (as the boy most
heartily believes) been glad to give him some.

“He was very good to me,” says the boy, wiping his eyes with his
wretched sleeve. “Wen I see him a layin so stritched out just now, I
wished he could have heard me tell him so. He was very good to me,
he was!”

It may be asked, is the above an over-drawn picture of what is frequently observable in coroners’ courts? If answered in the negative! surely the time has come for the reception of additional evidence, with the view, not only to improvement in accordance with the age in which we live, but for the maintenance of the legitimate object for which coroners’ courts were first established, and which they profess to uphold in all the integrity of seeking _the truth_, _the whole truth_, _and nothing but the truth_. Under these circumstances it becomes an imperative duty to record cases where discrepancies exist or have existed.

Case 1.—In the village of R—, a few years since, a young woman denying her guilt to the latest moment, was one morning discovered by her relatives entering her bed room, apparently in a dying state. Observing the clothes saturated with blood, they sent for a medical gentlemen, who immediately attended, and soon ascertained that the cause of the hemorrhage arose from her having been recently confined. On accusing her of the fact and enquiring where she had put the child—with quivering lip and trembling hand, she pointed to the opposite side of the bed, beneath which, was a box, containing the body of a full-grown infant. Externally it appeared perfectly healthy, but the face was dark and tumid, especially the lower part and around the neck, a mark, as if a cord had been tightly held or fastened, was distinctly visible. At the coroner’s inquest held shortly after, the medical attendant deposed, that collateral evidence proved the child was born alive, and the mark alluded to, corroborated his opinion that the child had been strangled. On this evidence, and this evidence alone, as no cord, tape or missile could be found, the jury, at the coroner’s suggestion, returned a verdict of “wilful murder.” At the following Assizes, in Norwich, the judge who tried the culprit, elicited from the medical gentleman, that it was possible for the child to be strangled in its birth from natural causes—that the cord or funis belonging to the child, itself might surround the neck, and by impeding its birth, produce strangulation and death. Under the direction of the judge, the jury immediately returned a verdict of “not guilty,” and the prisoner returned home to her friends, who rejoiced in her acquittal, and believed her an injured person.

Had the coroner at the inquest ascertained the above fact, she would not have been committed to be tried for murder under his warrant, but for misdemeanour, concealing the birth of her child. Thus she narrowly and properly escaped the punishment for the capital offence, but improperly escaped the punishment which would have been awarded her by the offended laws of her country, for conduct she richly merited and deserved.

Case 2. The wife of an agricultural labourer, in the parish of I— was in the habit of going to work in the fields, and leaving her children without fire or food from morning till night, and if on her return she found them crying or murmuring, she would flog and send them to bed supperless. One of the poor children was attacked by the measles, and although the eruption had partially made its appearance, she carried it to the field where she worked, laid the child under a fence, as it was too ill to sit up, and there it continued the whole day, part of the time exposed to a fog off the German ocean, which rendered the surrounding atmosphere cold, moist and insalubrious. Returning homewards in the evening with her child, she observed it was getting worse, and two or three hours after, she asked a neighbour to come and see it, which she did, and advised the mother to send immediately for the parish surgeon. He promptly attended, but gave no hopes for its long surviving, as it was labouring under acute inflammation of the lungs, and in a few hours after his opinion was verified, for the child expired. Some days elapsed before an inquest was held over the deceased. The parish surgeon deposed the child died from inflammation of the lungs, following the measles. On being asked whether he did not think death was accelerated, owing to the child being exposed to cold, he said “No! on the contrary, I consider it beneficial.” In this instance, the medical gentleman was requested by the coroner to re-consider his statement, as he had always understood by checking such eruptions, they were liable to be fatal—but the parish surgeon would not retract, and the coroner rested satisfied, by merely reprimanding and cautioning the woman to take better care of her children.

Thus was inhumanity shielded in its career; as if the life of a child might be sacrificed with impunity.

Case 3. The daughter of a respectable tradesman, in the parish of I—unknown to a part of her family, gave birth to an infant. At four months old, she introduced it for a short time amongst them, as belonging to somebody else. When about to leave home, she engaged another woman to carry it part of the road she was going, promising she would soon overtake her. On reaching the village of L—, a distance of four miles from whence she started, the woman looked at the infant attentively, and thought it was dying. Being alarmed, she entered the first public house she came to, imparted her suspicions, and on close examination, found her fear was not groundless, for the infant had ceased to exist. A coroner’s inquest was summoned, and evidence given that the parent had expressed other than a mother’s fondness for her child. Laudanum had been purchased the night previously, from a shopkeeper in the village by her order, and on receiving it, she tore off the label which denoted the deadly poison, and the phial was subsequently found emptied of its contents. Here apparently a link in the chain of evidence was broken. Two medical gentlemen who made a post mortem examination of the body, deposed that laudanum had been administered to the child, but they were not prepared to say in sufficient quantity to cause death. {28}

A verdict under the coroner’s direction, was recorded that the child died by the visitation of God; but material evidence from other witnesses was withheld, which might have unveiled the mystery surrounding the death of the innocent, and the strongly suspected parties might have been brought to justice.

It is generally known, sooner or later, to habitual drunkards, that too much indulgence in strong beverages, particularly spirituous liquours, is followed by becoming more and more susceptible to their intoxicating effects, although partaken of in smaller quantities. This is owing to established facts; the liver becomes diseased, the nervous system becomes shattered, the brain itself participates in the mischief, so that reason losing its sway in the earlier period becomes permanently injured, and either madness or imbecility; premature age, or organic disease are the inevitable consequences. From the cradle to the grave, a predisposition to decay exists in every one which would far more frequently lie latent, until Old Mortality could no longer stay, did not this, the most disgraceful of all-exciting causes, thus step in and cut the thread of life when least expected, and probably least prepared.

Such was the case with a schoolmaster, who when living, resided in the village of H—. He prematurely suffered from Idiopathic irritation of the bladder, for on carefully sounding him, no stone could be detected, and therefore it was conceived, that inflammatory action in that viscus existed, which accompanied with pain at intervals, especially during the night annoyed him exceedingly. Disease advancing, he consulted a general practitioner in the neighbourhood, and subsequently other medical men, among them an eminent physician in Norwich. But the obstinacy of the disease soon caused his confidence to be shaken, and fearing the result, he yielded to the foolish solicitation of meddling acquaintance, who persuaded him to consult a notorious quack. Complying with their wish, he followed the advice given by the remorseless pretender to knowledge in disease, and applied bullock’s milts to the feet, partook of stimulants (ammonia and spirits of turpentine) in the day, with brandy and laudanum at night; on taking only two doses of the former, his anguish increased considerably, which became partially allayed by the laudanum, but no sleep succeeded—the expression “the complaint has flown upwards,” escaped the lips of the dying man, and delirium closed the scene.

To consult the accelerator of his death—the iniquitous quack—he undertook a journey of forty miles, only four days previously; and although the disease might eventually have killed him, still his condition was good, emaciation had made but little progress, and his appetite continued excellent. From taking stimulants, the gradual decay of nature was denied him. His agony was such, that in cases like his, an Infinite and Merciful Being has wisely ordained that collapse should take place, that the nervous system should receive a lasting shock, and thus was the schoolmaster the victim of credulity, relieved of his earthly pilgrimage.

Such a sudden termination in the death of this unfortunate being naturally aroused the attention of the neighbours. A coroner’s inquest was summoned, and the gentleman in office proceeded to his duty; but the cause of death not being ascertained to the mutual understanding of himself and jury, an adjournment took place. In this instance, though informed that a general practitioner in the neighbourhood attended the schoolmaster in the earlier period of his illness, yet the coroner neglected to call him as evidence, but observed to the jury he should take the phials left in the possession of the friends of the deceased, to have the contents analyzed. Returning homewards, he called on a medical gentlemen, stated his mission, and requested he would on a day named, attend and give evidence. This was assented to, and on the investigation being resumed, the question put to the witness was “What is the nature of the disease, and the cause of death?” he replied, “He could not tell, as he had not been consulted by the deceased during his illness, but he believed the medicine prescribed was harmless—would neither kill nor cure—although he did not approve of the treatment.”

Here the coroner rested satisfied with this superficial enquiry in search of truth, and addressing a readily assenting jury, advised a verdict should be recorded that the deceased died by the “Visitation of God;” and thus was suffered to escape, one of the finest opportunities to expose and punish the unpardonable vanity of a dabbler in physic, who openly, yet certainly, disclosed the fact that he and his fraternity are allowed to deprive with impunity the lives of the weak minded, the most to be pitied among Her Majesty’s subjects.

Case 5. The last example necessary to quote at present, more recently occurred in a village in the county of Norfolk, which requires peculiar notice and consideration, owing to the respectability of persons connected with the affair.

Reports of an extraordinary character had been in circulation several weeks before the event transpired; and this enquiry actually rested on what is termed in medical language Mala Praxis. {32}

A poor agricultural labourer, William Swann, came to an untimely end, through circumstances of an aggravated character, leaving a widow and nine children to deplore his irreparable loss; for among this, the humblest classes of society, there are ties of affection naturally entwined by which they are endeared to each other, more than is frequently observable among grades of a similar character in towns or cities. From their means being limited, their fare less sumptuous, their sayings and doings more immediately exposed, and their abodes being apart from the habits, bustle, and temptations existing in more populous neighbourhoods, are satisfactory reasons for the truth of the above assertion.

The unfortunate deceased observed his health giving way in the month of August last year, and he consulted the parish surgeon, Mr. John Coleby, who found him labouring under irritation of the left kidney, produced by the detention of gravel, which lodging there, pained him exceedingly. The treatment suggested, was attended with various results, sometimes he was relieved for a few days, then he relapsed, and after several weeks illness, a small stone escaped into the bladder.

Swann’s health, however continuing impaired, his wife replied to various inquiries, “he was no better,” and having remarked that she considered the parish surgeon inattentive, a warm-hearted lady, (Mrs. Shirley) expressed a wish that the poor man should consult her medical man, Dr. Bell, residing in Norwich, in whose skill and medicine she had great confidence. Swann consented—was placed by Dr. Bell, on his arrival in Norwich, under the care of Mrs. Phillips’, and the testimony of the different witnesses at the inquest, afterwards held on the body of the deceased, proclaims the result.

The evidence first called, was Mrs. Swann, the widow of the deceased, who stated “My husband was 45 years of age. In the early part of last harvest he was very ill, and he applied to the parish doctor, Mr. Coleby, who attended him until after Christmas, and I told Mrs. Shirley, I did not think Mr. Coleby did justice to him, so she sent him to Norwich to be under her medical man, Dr. Bell. He went on Wednesday, the 11th of February, in a carrier’s cart, and took lodgings of a Mrs. Phillips, in Union Place. He told me that Dr. Bell attended him the same day, that he went up and passed five instruments into his body. He said that Dr. Bell hurt him very much and he (Dr. Bell) passed his instrument up further, which caused a large stream of blood to come from him. Dr. Bell gave him some medicine and continued to attend him a fortnight, when he said he would not take any more. On hearing him say so, Dr. Bell asked him who he would have come to him, he said Mr. Webber, as he was with him when Dr. Bell passed the instruments. Dr. Bell wrote to Mr. Webber to attend, but he would not; I went to Norwich that day, and by my husband’s desire I called on Mr. Webber, and asked him to come and see him; he came and examined him, and said inflammation had taken place, but he would do his best endeavours for him. Mr. Webber attended him five weeks, and he came home on the 30th of March last. Mr. Coleby attended him the next day, and continued to attend him until he died, on Friday, the 14th of May—he frequently complained of his kidneys.”

The next evidence was Margaret Phillips, an experienced nurse, who stated “Her lodgings and services were engaged by Dr. Bell, and that the deceased was placed under her care, on the 11th of February—she was present when Dr. Bell sounded him for stone, which was done in the presence of Mr. Webber. The instruments he used with considerable force, but he could not succeed in passing them. The poor man suffered very much, which no doubt induced Mr. Webber to call out “That’s not my way of sounding, let me try.” But Dr. Bell refused. He jumped up and getting another sound, attempted to pass it with no better success. I called out “Dr. Bell, the instrument is cold, for God’s sake have some hot water, and oil it well,” for previously he had only oiled it slightly. He took my advice, he used another instrument, and applying considerable force, he passed it through, and during the time the patient suddenly called out “I feel it go through somewhere, it hurts me dreadfully.” After this, Dr. Bell said to Mr. Webber “do you try,” which Mir; Webber did, but observing “I prefer my own sound,” which he, without difficulty, immediately passed. I saw some blood escape, not much, immediately after Dr. Bell withdrew his instrument.

“Shortly after the deceased went out to see about his linen which was left at the public house where the conveyance stopped, that had brought him to Norwich. This was a short distance from my house, and soon returning, the deceased observed that he was in dreadful pain, had been losing a deal of blood, and on calling for a vessel, the blood came from him in a stream. He continued to bleed some time, and becoming alarmed, I called upon Dr. Bell to come to Swann’s assistance. He quickly attended, and soon after the bleeding ceased. From that time the deceased continued to be a great sufferer, and on Dr. Bell visiting him _three_ days after, I said to him privately, I am sure you have injured that poor man, I never saw a man lose so much blood before from sounding, nor yet complain of so much suffering. Dr. Bell inquired of the deceased “whether it was Mr. Webber or him that hurt him,” he said “you, sir!” Dr. Bell then asked “are you sure it was not the other gentleman,” the deceased said “No—it was you, I did not feel Mr. Webber’s instrument pass, he gave me no pain.” Dr. Bell continued to attend him a fortnight or three weeks, she could not recollect which. No other medical man attended during this time, but the poor man getting worse and worse, Dr. Bell brought Mr. Webber again to see him. They did not agree as to their treatment of him, Mr. Webber suggested one course, but Dr. Bell refused to do so. They left my house, and I do not know what passed, but Dr. Bell shortly after returned, and said “Nurse, at your peril you are not to suffer any medical man to interfere, he is not to take any thing except from me, as Mrs. Shirley said he was to be entirely under my care.” I said “of course Dr. Bell I do not want to bring any medical man in, the only gentleman that has been, you brought yourself.” The deceased had no other medical man at that time to attend him; he continued to get worse, and I was obliged to call up Dr. Bell one night, and then he was very much frightened, and asked “What can be the cause of all this?” I said, “The cause is what Mr. Webber told you would be the result—ulceration,” and I exclaimed “Oh! good God, what will become of the poor woman and children?” he replied, “Mrs. Shirley will take care of them.” I begged and prayed of him not to go out of the way and leave me with a dying man without doing something himself, or sending another medical man; he then went up-stairs to Swann, and asked him again whether he would take his medicine, and the man said “No—no more,” I heard him say so. When Dr. Bell came down stairs again, he asked “Who can have set this man against my medicine?” I said, “Go up-stairs and ask him in the presence of witnesses”—Dr. Bell did so, and said, “My good man, who set you against me and my medicine?” He replied, “No one but the pain the medicine gave me.” Dr. Bell then left the house and ceased attending him, and Mr. Webber was called in. He ordered the deceased some medicine, and fomentations to allay pain, which were continued several days. He called in Mr. Gibson to witness the condition of the patient, for he was afraid the man would die in the state he was then in, and they talked about medicine and treatment. Mr. Gibson called once more, and said “the man was in good hands.”

“The deceased came to my house on the 11th of February, and left me exactly seven weeks after. Dr. Bell called on me at the end of six weeks, and said that “Mrs. Shirley insisted on the man being sent home, and that I should not be paid more than six weeks lodging.” I said, “I could not send him home on my own account; but that Mr. Webber would send him home when he thought fit.” Mr. Crickmay, another surgeon had also seen Swann several times, with Mr. Webber, and that he had nothing further to suggest.”

Mr. John Coleby deposed, “I am a surgeon, residing at North Walsham, and I was summoned to attend the deceased last August; he complained of pain across the loins, particular in the region of the left kidney, and I treated him accordingly. After some time I suspected a stone had escaped into the bladder, I passed an instrument twice without any difficulty, in November, the first time without success, but the second time I detected a small stone. At that time his health was so indifferent, as to lead me to believe had I operated upon him, his life would have been the sacrifice. I then prescribed such medicine as I thought conducive to his benefit, with a view to prepare him for the operation, and I remarked to him previous to his going to Norwich—put yourself under my care, you have a stone in your bladder, but I cannot advise you to be operated upon immediately. He however went to Norwich, and I called upon the deceased whilst he was lodging at Mrs. Phillips’. I never saw a man so much altered as he was in so short a time, which I consider to have entirely arisen from the bad treatment he had received—I really thought he would die. Mr. Webber had previously opened an abscess, which had formed in the central lobe of the testis and pus {39} was escaping. On the 30th of March last, he returned to Knapton, and I called to see him the following day, I found him in a very debilitated and exhausted state. He was then labouring under irritation of the bladder, accompanied with an inflammatory affection of the left kidney. He continued to linger nearly six weeks, suffering great agony to the last, and on the 15th of May, I performed a post mortem examination on the body of the deceased, in the presence of Mr. Webber and Mr. Crickmay, of Norwich; Mr. Evans, of Coltishall; his assistant, Mr. Tibbetts, and my own assistant, Mr. Cheverton. I examined the left kidney, which was considerably enlarged, and in the renal capsule connected with the ureter, there had evidently been inflammation, for an abscess had formed there, which caused his death. I have no ill feeling towards any one in stating it to be my firm opinion, that this abscess, like all the others in his case, resulted from the violence used by Dr. Bell, in passing the instrument, and that which hastened his death. Since the man returned home, he told me frequently ‘he owed his death to Dr. Bell.’”

Here the coroner, turning to the jury, observed, “The deceased died from natural causes, shown in the evidence of Mr. Coleby, for his death was owing to an abscess in the _renal_ capsule of the kidney, and that is sufficient.”

Dr. Bell, who had been sitting next the coroner, in a juxta position with one of the jury, with whom he was observed to be often earnestly talking, then rose, and said “He could not leave that room without offering a defence for the sake of his family and friends, as he perceived that his character was at stake, and in spite of the remonstrance used by Mr. Webber. Dr. Bell obtained the sanction of the court, and was proceeding to state, that he was M.D. surgeon, when Mr. Webber objected such was not evidence, that the coroner was at liberty to call Wm. Bell, of Norwich, but that this witness must state his qualification on oath. He was then formally sworn, and stated, “I am a surgeon M.D. at Norwich. The man was sent to me from Knapton, by Mrs. Shirley, (whose letter the witness read.) The man reported to me that he had been ill on the previous harvest—that he had been attended by Mr. Coleby daily, and that he had been under his treatment until he visited me on the morning of the 11th of February. His symptoms led me to ask him if Mr. Coleby had ever examined his bladder, naturally suspecting that he was labouring under stone. He said that Mr. Coleby had done so, and told him that there was no stone. That for months he had passed blood, and on some occasions something remained at the bottom of the vessel he used, if allowed to stand. He appeared to be extremely weak and emaciated. I took him to my house where I examined him with a sound, and immediately detected a small stone. I then wrote to Mrs. Shirley, of which I have kept a copy, but that lady has lost the original. Dr. Bell then read a note in which was stated that he had examined the man, who was in a deplorable state. That he had a small stone in his bladder, and had evidently been under a dangerous affection since last harvest—she could adopt one of three courses—_she could place him under the care of Mr. Coleby again_, _and when his attention was more immediately directed to the case_, _perhaps he would be more fortunate in detecting the nature of the complaint_—or she could send him to the Norfolk and Norwich Hospital—or she could place Swann under his care, and he should be happy to attend without any charge, and the only expense would be for his board and lodging. Whatever plan should be adopted, let it be with the sanction of Mr. Coleby, and if he found relief from that gentleman, he was not to be taken from him, but strictly to attend to his (Dr. Bell’s) directions pro tempore. He also read a note from Mrs. Shirley, wherein she sanctioned Swann being under his care.