Second report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts.

  • Great Britain. Committee on Coroners.
Date:
1909
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Licence: Public Domain Mark

Credit: Second report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts. Source: Wellcome Collection.

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    25 May 1909.] [ Continued. blow was discussed by many witnesses. One said it was strong enough to have felled an ox, and another witness said it would not have hurtafly. The post-mortem exami- nation revealed not the slightest evidence of any injury— no bruise, no mark, no appearance of a blow; but the man had all the symptoms of a typical failing heart; he had very dropsical legs and advanced heart disease, and the excitement of the fight and working himself up into a passion had been too much for him. 6276. Still, do not you think that there may be some cases in which possibly a post-mortem might very properly be dispensed with. Take the case of a burning accident P—Yes, a burning accident, for reasons chiefly connected with proper restoration of the body. 6277. Or take the case of a man run over by a railway train ?—There again we may find on a post- mortem something which may have produced the fall under the railway train, or some given disease which might account for the man being in the position he was found in. 6278. Even though he may be cut to pieces P—Yes, even though he may be cut to pieces. 6279. Take the case of a man being caught up in machinery and killed that way ?—Yes, of course, that is a case in which perhaps an exception might be made if the man is obviously in perfect health and is ce2n to be caught up. 6280. Or, say, a colliery accident, in which a number of people are killed?—In the case of a multiple accident where several people are drowned, as in the case of a ship going down, then I do not think it would be necessary. 6281. Would you not then allow the coroner to have a discretion, as he has at the present time ?— Yes; I think the coroner should have a discretion, but I would like to see some rule introduced making the holding of a post-mortem much more a matter of necessity than it is at the present time. 6282. You mean that you would not restrict post- mortem examinations, but rather encourage them ?P— Yes, I would very much. _ 6283. Especially where anything is to be gained by it P—Yes. 6284. At the same time you would bear in mind the question of expense where it might properly be considered ?—Yes, I think in some few cases the expense might be considered. 6285. Do I correctly gather that you think a special pathologist should make post-mortem examinations, and a special pathologist only ?—With the exception of men who are constantly employed in such work, such as one of these police surgeons who would practi- cally become a skilled pathologist, I honestly think that a man specially skilled in this work should make every examination. 6286. In a very large number of cases the post- mortem examination might be made by an ordinary practitioner, might it not?—I think it might, but I do not think always to the best advantage from the point of view of the inquiry. 6287. Take cases of valvular disease, or cerebral hemorrhage, or rupture of an aneurism of the aorta, which are quite obvious?—Yes, they are quite com- petent to make such examinations ; but until you open the body it is impossible to discover whether you are not going to find something else. Then it is often too late to deal with the case properly if the man is not a skilled pathologist. : 6288. Have you run across many cases in which such a condition of things existed ?—I have come across certain cases in which it would have been difficult to say which was the actual cause of death, from a multi- tude of lesions of different kinds. 6289. In those cases have they been deaths from natural causes ?—Yes, generally—those I have in mind. 6290. Supposing that, as the result of a post-mortem examination, it is palpable that death is due to natural causes, would you not consider that ordinarily sufficient ; or do you think it is necessary in the interests of the public that the actual technical cause of death should be ascertained 2—I think it is most-desirable that the actual cause of death should be ascertained, 2960, 6291. So doI; but I am putting it on another basis. Do you think it is necessary P—Yes, I think so. 6292. You will agree, of course, that we cannot hope to arrive at the ideal state >—Yes, I quite agree. 6293. And you also consider, I am sure, that expense must be an item of consideration ?—Yes. 6294. And in many cases expense is the only difficulty in getting the ideal condition ?—Yes. 6295. That is perhaps one of the primary difficulties in the present case?—Yes. I think myself that fixed salaries, and giving the coroner power to hold a private inquiry, should go far to diminishing expense at the present time. 6296. I do not disagree with you in your views; I am only looking at the probability of Parliament according power, which would cause a lot of expense to be incurred ?—Quite so. 6297. Take the case of persons dying in an outlying district ; do not you think that ordinarily the country practitioner would be able to make a post-mortem in ordinary cases ?—I suppose one would have to admit that he was able to make a post-mortem examination ; but I do not think in my experience I should like to put overmuch confidence in the findings as a rule. 6298. I am not dealing with extreme cases; it is ordinary simple cases such as I refer to ?—I think one grave objection to practitioners making post-mortems, especially in cases which they have been treating, is the tinge of bias which must necessarily come in as the result of such an examination. Ina country district especially, where a medical man is practically the subject of every kind of village gossip, he is a person in the public eye. He treats A.B. for a particular disease, and A.B. we will suppose, is found in the river. This is a case that came within my own knowledge. A.B. commits suicide, throws himself into the river, having been treated by a medical man for rheumatic-gout for two years. The practitioner makes the examination, and finds that the whole mischief was a stone in the kidney. 6299. Have you any evidence of such cases occur- ring?—I have. This is one particular case that occurred in my experience when I was away on my holiday, in which every single person in the village had not got a good word to say for a very sound and able medical man, simply because a statement had got about that a post-mortem had been made by him on one of his cases and that certain facts had been suppressed. 6300. You get difficulties here and there in cases at all times P—Yes. 6301. And under any circumstances P—Yes. 6302. I am interested in your mention of the freezing chamber. Have you any information as to what the cost of the installation of a freezing chamber amounts to P—I am afraid I have not. 6303. Not approximately P—I am afraid not. I ought to have ascertained it. 6304. Or of the upkeep of it >—I am afraid I cannot give you any figures on the subject. 6305. What is the temperature in the freezing chamber —We keep ours down to about 32 degrees Fahrenheit in each chamber. 6306. How is it kept up—by ordinary ice o—We have got an elaborate dynamo which works a system of alternate compression and relaxation of carbon dioxide gas in cylinders, and then brine circulates through these chambers, which are constructed to carry, —I think it is four coffins each. 6307. Can you connect it and disconnect it at will ? —In our installations the freezing machine works only for the chambers, and I do not think it could be cut off from them. It is only installed for the purpose of cooling those particular chambers and not for any- thing else. 6308. You do not know whether a system could be obtained which connects and disconnects at will ?—I should think it is quite possible. 6309. The advantage of this freezing chamber is, of course, that the body could be kept free from decomposi- tion P—Yes, and in a country district a body could be A 3