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40
In the case of deaths not certified by medical practitioners
a more drastic change is needed. The coroner's jury may have
its good uses, but its seven hundred years of hoary antiquity must
probably stand as one of the best excuses for its existence. A
fairly extensive experience of such bodies compels me to say
that, whilst innate commonsense and shrewdness often constitutes
their salvation from totally fallacious findings, they are
exceedingly apt to be swayed more by irrelevant items of
evidence than by those which are both relevant and admissible.
Not infrequently their verdicts are arrived at without medical
guidance, and are couched in terms which display a want of
appreciation of the real meaning of the words they have heard
and even of those which they have themselves used.
The law has in view, in the holding of coroner's inquests, the
highly important duty of inquiring into cases of homicide or
sudden death with the object of separating out those deaths due
to criminal intent.
State medicine has in view an object no less important, for
correct death certification depends upon correct medical
nomenclature; upon the latter public health statistics are
entirely based, and upon the last legislative measures for the
betterment of public health are very largely founded.
There is a distinct necessity, in my opinion, for the regular
co-operation of medical with legal knowledge in all inquiries into
sudden and unknown causes of death. Every coroner possessed
of legal qualifications alone, should have as an adviser a medical
man of extensive pathological experience, and post-mortem
examination should be the necessary preliminary to every
inquest. Until these essentials are carried out the findings of
coroners' juries must be accepted with very considerable reserve.
I give some verdicts recorded in this district during 1908 to show
the curious wording sometimes adopted by juries:—
"Suffocation—want of fresh air, caused by collapse of
houses."
"Bursting of abscess in abdomen and inflammation of
lungs accelerated by fractured patella and injury to the side
caused by a fall on ground when alighting from a tramcar
in motion."
"Disease of heart and other organs caused by
alcoholism, otherwise natural."
"Disease of heart and liver at a time when he was
under chloroform for the purpose of an operation."