v<^. - .0. IMAGE EVALUATION TEST TARGET (MT-3) \'\J 1^ ^^ I.I 4S 50 IM M 1.8 1.25 1.4 '■* <« 6" — ► p> ^^i ^P} >> J Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques Technical and Bibliographic Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. D D D D D Coloured covers/ Couverture de couleur I I Covers damaged/ Couverture endommagde Covers restored and/or laminated/ Couverture restaurde et/ou pellicul6e Cover title missing/ Le titre de couverture manque Coloured maps/ Cartes g^ographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Reli6 avec d'autres documents Tight binding may cause shadows or distortion along interior margin/ Lareliure serree peut causer de I'ombre ou de la viistortion le long de la marge int^rieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se pc signifie "A SUIVRE", le symbole V signifie "FIN". Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les cartes, planches, tableaux, etc., peuvent §tre film^s d des taux de reduction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul clichd, il est filmd i partir de Tangle sup6riei>r gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images ndcessaire. Les diagrammes suivants illustrent la m6thode. 1 2 3 1 2 3 4 5 6 I irr iBibliotfje quei^ationalf bu (Quebec V-.- SIX MONTHS' MEDICAL EVIDENCE IN THE CORONER'S COURT OF MONTREAL. BY WYATT JOHNSTON, ivi.D., Montreal, AND GEORGE VILLENEUVE, M.D., Montreal. (Reprirded from the Montreal Medical Journal, Augwt, 1893.) .^' K£ ./^fjV/ '^»*W<-r». SIX MONTHS' MEDICAL EVIDENCE IN CORONER'S COURT OF ^MONTREAL (January to June, 1893).* ANn THE Bv Wyatt Johnston, M.D., MONTRBAI,. GkOHGE ViLl.BNKUVK, M.D. MONTUKAL. At the coramencement of the present year, when, on account of his long experience in criminal matters, our present energetic and capable coroner was appointed, it was intended that his duties were to be purely judicial, and that medical questions in connection with coroners' inquests were to be investigated by a physician specially appointed for that purpose, whose duties should correspond with those of the " coroners' physicians " or " medico-legal experts " of other countries. These duties having been entrusted to one of the writers since the beginning of the year, or, in case of absence, to the other, we think it well now to review the medical evidence given be- fore the Coroner's Court during the past six months under the new system. t We wish first to express our thanks to the members of this Society, and to the medical profession in general, for the cor- dial support they have given, from first to last, in effecting some much needed changes in connection with Coroners' Court in- quests. We also wish to thank the members of the Provincial Government for the great interest they have taken in the matter and the uniform courtesy with which all suggestions concern- ing it have been received. ♦ Read before the Montreal Medico-Chirurgical Society, Juno 23, 1893. •■ As the present paper is chiefly of ii general nature it seemed preferable to make our communication a joint one, although most of the evidence has hitherto been given by one of u,s^(Di;.,Jo}jnston)., ., ; ' • • '« ■ ' ' . • . '. J > ' ' . < • • • I • « • * 1 . T i ■ . > .;-.'.'!i.54690" ••:•,•'-'.'■• - ■ .>• .,r*^»- .,■•-(* . i A beginning has already been made in the direction of placing matters concerning medical testomony at inijiiests on a dill'ercnt footing, but owing to some technical difficulties in arranging the duties of this new medico-legal office, we have only been consulted in a relatively small |)roportion of the total iiKpiests. For this reason a communication limited to our own personal observations would not be fairly representative of the evidence in the Coroner's Court, so we have, in addition, supple- mented our own observations by studying the testimony given by medical witnesses in cases where we were not consulted. All internal post-mortem examinations ordered by the coroner or jury were made by the expert, but as autopsies are only called for in a small number of cases, many of the inspec- tions of the body, which constitute the majority of the examina- tions, were made by other medical men. A radical change has not yet been found feasible under the present law, though I may state that the present coroner is strongly of opinion that autop- sies should be performed in every case where it is necessary to hold an inquest. Our information as to medical testimony given at inciuests where we were not present has been obtained from the records of inquests deposited at the Crown and Peace Office.* These documents are at all times accessible to any one who may wish to see them, and therefore the information obtained from them is not of a privileged or secret nature. During the six months ending June 30th, 1893, 202 in- quests have been held in the Montreal district, out of which we have been called to give testimony in 70. Daring the same period 26 autopsies have been ordered, all of which have been entrusted to us.f In the remaining inquests, 130 in number, the examinations were made by 68 different medical men. Except in specially important cases the expert does not examine the bodies of those who have been seen during life by other medical men. It jeemed expedient in the present paper to treat the medi- ♦ We linvc to th.iiik Mr. C. Doucet, Clerk of the Crown imd Peace OlUoe, for kindly aidiiiK lis in consultiiifr tiie records. t We take this opporl unity of thanking Coroner McMahon for the uniform courtesy and consideration wiiich hu has slio\^w us in our capacity of ex|)erts, which has made our work under him svecja^ly agK'eiible', '.','' • "X, « » . • » k t > « • • « •1-4 ^ '■>.. I t . f I "f-o.. cal evidence 'n a general statistical way only, reserving for future and more scientilic papers the details of the cases. (Joraparing the work of the Coroner's Court with that of two years ago, in 18'.)0 and li^Ol, we find that then al)out 240 in- (juests were annually held in the district of Montreal, and in these 12 autopsies were made, so that at present the number of inquests is nearly twice as great, and that of autopsies is about four times as great as under the old system. Taking the population of the district of Montreal as 300,000 (which is well below the mark), we find th-at 0.8 inquests were then held per year for every 1,000 inhabitants. In Phila- delphia 2 per 1,000 are held annually, and in Liverpool 1.7 public inquests per 1,000, and as many more coroner's private inquiries, so that the number of inquests in Montreal is rela- tively small as compared with other large cities, the frequency for the past half year being at the rate of 1.32 per annum. Here, as elsewhere, of all the cases brought to the notice of the coroner, only a few finally prove to be medico-legal. In Liverpool, of 900 inquests held in 1892, only 4 verdicts of mur- der %nd 8 of manslaughter were found, or in other words, less than 1.3 per ceut. of the suspicious deaths were found to be due to criminal violence or negligence.* In South-west London, out of 20,000 inquests during 20 years, there were 8 verdicts of murder, 14 of manslaughter, and 59 of infanticide, or 0.4 per cent, of criminality.! That so much material must be sifted in order to detect criminal cases affords an explanation of the fact that we have no startling or sensational tragedies to report to you to-night. Possibly if more autopsies had been held more crime would have been detected, and certainly in two cases the circumstances seemed sufficiently suspicious to warrant us, as medical men, in suspecting foul play, although as the juries did not think it necessary to order autopsies in either of them no positive state- ment can be made on this point. In the Province of Quebec, as we know, except in exceptional cases, it is the practice only to hold autopsies with the consent • F. W- Lowndes' evidence l)efore committee on deatli certitication, 1893.— //rt7w/j i\fid. Journal, May 6, 1893, p. 902. t Braxton nicks.-//,/.7. ..,.,.^^ 6 of a majority of the jury. Why a juryman should he supposed to know better than tlie coroner or the medical witness where an autopsy is needed is a matter which we cannot pretend to explain, but, such being the law, there is at p.-esent apparently no remedy but patience. [n Montreal to hold 240 inijuests annually meant that 2,880 jurymen must be empanelled each year to consider the evidence. Were the coroner permitted to order an autopsy when necessary to establish the cause of death, not only would the entire medi- cal evidence be ready for the jury at its first session, but as in three-fourths of the suspicious deaths natural causes of death could be demonstrated, three-fourths of the iiujuests would be prevented, in other words, 2,100 of the citizens of Montreal would annually escape the annoyance of having to sit on juries in order to bring in verdicts of death from natural causes, and the attention of the coroner and h.is juries would be concentrated on the few really criminal cases. Unfortunately we learn from the very highest authority that the holding of autopsies in order to prevent inquests is illegal and contrary to the spirit Oi" the British criminal law. This is a matter to be regretted, as it causes much loss of time and unnecessary ^ -pense. Tlie British Coroners' Act of 1887, however, empowers the coroner to order an autopsy to be performed before the jury is summoned ; were this the case here much of the jurors' valu- able time would be saved in the minor cases. Education of •Jury men. — Out of 1,200 jurymen empanelled for a series of 100 consecutive inquests 879 signed their names and 321 made their marks. The percentage that signed is 73.2, and I am informed by Mr. Biron, Coroner's Clerk, that a number more were able to write but refrained from doing so ; some from modesty, others for fear of soiling the paper. We may assume that about 80 per cent, of the jurymen were able to write, but from the appearance of the signatures I should judge that less than 50 per cent, were persons who had written sufficiently often to give any character to the handwriting. Some of the most sensible verdicts were rendered by jurors, none of whom could write, and some of the most absurd ones bore the autographs of all twelve jurors. >^.„ .sytv^. InquestH in past Six Months. — In the 202 inquests held from January to June, 1893, the following verdicts were rotarnod. We have placed in separate columns the cases in which we were consulted as experts, and also those in which autopsies were made. In 88 coses out of 202 (that is to say, 43 per cent.), the in. vestigations were what is known as ex-parte, or held hy the coroner without summoning a jury. In these cases the sus- picions of crime were either very slight or shown to he ground- less upon preliminary inquiry. The regular fees were not paid to medical witnesses in these cases, except in three instances where the medical expert was consulted ; in the remainder the testimony was informal and not taken under oath. The practice of holding these ex-parte in- (juests appears to have been discontinued, none being recorded in the month of June. In other words, public records are not kept of the cases in which, upon inquiry, the coroner does not find cause for summoning a jury. Table showing relative frequency of in([uests before coroners, of joroner's in(iuiries without juries, and of autopsies, for the half-year from January to June, 1893. The percentage of inquests in which autopsies were ordered is also given for each month. This has increased from 7,3 per cent, in the first (juarter to 14.6 per cent- in the second. Months, 1893. January' February March . . . April — May* — June Inquests before Jury. 9 11 14 13 22* 14 Inquiries without Jury, 14 24 21 15 14 Ot Total num- ber of deaths a „,„„.:„„ investigated ; AutopMes. by coroner. , 2.T .!,'"> 35 2H 3C. 44 3 (13 percent.) 2 (6 per cent.) 1 (3 percent.) 6 (21 per cent.) 4 (11 percent.) 10 (22 per cent.) Total . .1 113 1 88 i (57 per cent.) i (43 per cent.) £01 26 (12.8 per ct.) *One inquest in a case of arson is omitted, as having no bearing upon medical [evidence. t Since the 1st of June no public record is made of the facts elicited by coroner's ; inquiry in the cases where it is not necessary to summon a jury. 1 ./"■' :?■' a Table showing the verdicts of tho Coroner's Court for the District of Montreal from January to June, 1893, including the conclusions arrived at in ex-parte inquests held without jury in minor cases ; these are also placed in a separate column : — Vkkdicts. ii h 1 1 1 J i! 1 I "a J ^ 2 1 1 o S 1— HOMICIDAI- DkATHS, \f iLimliLii^rlitHr * .. 1 Jury un■#■• "i Total 7 5 12 5 III.— AOCIDRNTAL DkATmu. Fall into Hold of ShlD "i 1 7 1 3 \ 1 2 2 1 4 i 1 1 7 1 i 1 3 3 2 i 2 1 2 1 ■■ 1 10 4 » 3 2 1 1 3 1 2 2 2 1 1 1 9 1 4 3 1 1 11 1 1 1 1 1 1 1 1 KiLilwav ApiMflfttif .!■■ - 1 Str*'**f (Jiir ** Kleviitor " CarriiitPfi ** .....•*( "l Tobogganing " Machinerv *' •• Firemen on Dutv Others Suffocated bv Smoke Fall of BuildinK FallofDerrick Fall down Stair? •• BlastinK Accident Explosion of Water Pipe Burning ycaldinjc Iiihii lation of Gas •• Choked by Food Hseinorrbaee Umbilical Cord ] Over-Laying (Suffocation of Infant in Bed) Accidental Drowning i Administration of Chloroform 1 Sudden Death from Lead Colic Poisoning by Mor )hia " Soot ling Syrup " Chlorodyne lAnticholerique) Insolation (Sunstroke) Exposure • • Paralysis from Exposure & Intemperance! • • Total 12 1 39 37 7C 5 '•«»» 9 Vkbdicth. IV.— Dkatiih from Natukai, Cauhks. 1. Nfirovi Si/Miem .— Apoplexy Citrebrul lliiMiuirrhiiKe AbscoHM of lirniii CoiiKeMlioii of Kraiii ■ - MfiiiiiKitiH I'anilysiB 2. (hrrutatorii Si/hIi-hi :— lloart DiHoado Fatty DeKeMoriition of lloart • Aneurism. Syncope of Ili-arl • !feartl)i.seaHeiiKKravutcd by [ntempur'nce Syncope of (leiirt cauHcd by Intemperance Cardiac Asthma 3. llfHplratdrij Simtem .— Asphyxia 1 Pnoiniionia H ConKUMtion of liUnK!^ 1 Pneumonia or Heart Disease i I Inllamination of LunKS I 1 Pulmonary Kmbolism | .. Iltcmoptysis, Phthisi.-* 1 Consumption, Phthisis 8 Capillary Bronohilis I •• Pulmonary Apoplexy caused by Emotion- 4. Dli/cstii}f SiiHtent : — Inflammation of Buwels I'holera Morbus Diarrhoea Peritonitis Cancer of Liver Hepatic Colic Japindice 5. Ut'inavu System : — Urethral Fever fi. Generative SuHlcm : — Puerperal Fever . Metrooeritonitis . Other Dine a Hen : Purpura Dropsy Infantile Debility Senile " Stillborn Sudden Death from Lead Colic ■ Tumour Incurable Disease Intemperance Total. Mo 1 1 18 1 1 1 1 1 1 3 H 10 1 1 1 1 1 o S 1 '..^''' ^-..-^ 10 Vkkiiiots. rt 3 -l v.— Opkn Verdicts. Sudden Dciitli— No ciuiso assigned 3 l.'nknowii (^Husew 8 Nntural Caiii'es S Unkni>wn Niiturnl Ciinscs t^anadiiin OholiTii or I'oisoninK Found Drowned Total. 16 Summary. I I Homicides •• •'• Suicides " 7 yiccidents ''^ '^9 Niituriil Dea'ii 5!l If) Open Verdicts 10 li Total 88 70 13 — Ma 18 1 5 S7 7(1 18 131 o H 24 4 12 7 on the fresh cadaver. In this way there is no nuisance or o. danger to health. hi Comparing the results of the past six months with a period jg of six months in 1890, v e find that then in a half-year, out of l:i' j^ inquests, in 16 cases the verdict was simply " found dead.' /'k and in not one of th 'e was an autopsy made ; out of 7 cases ^ of cerebral apoplexy no autopsies were made, and for one vei jj^ diet of " cerebral congestion " no medical testimony was taken " Synecopy " of the heart was responsible for 7 deaths, no autop },n siea being ordered, and pulmonary congestion for 4 cases, o: ^^ which 3 were in the case of unknown persons found dead — n j^, autopsies. One case died of a " broken heart," and one o ^\q " angelis pectoris," 9 were found drowned, 1 accidentally Qf drowned, and in 8 cases medical testimony was not called for fiig To a certain extent, " nous auons chanyS tout cela^'' bu q^ even during the past six months some medical opinions hav ^gg been given which is sufficiently remarkable. I mention a fe* ^^ only. " Sudden death from hepatic colic " in a child thre |^^, days old, and withoul, jaundice, is odd, to say the least. " Coc ^ j gv'jstion of the brain caused by fatty degeneration of the heart ^ X. I 15 also an original idea, and worthy of a niche in history. Sud- len death from " metro-peritonitis " in a patient who seemed be in perfect health up to the moment of her death, is an Observation which it falls to the lot of very few to make. In |ne case, when the patient com{)lained of pains in the region of le stomach for several days before death, and had a consider- able haemorrhage on the night of his death, we find the state- lent that death " must have been due to heart disease or ineuraonia." In half of the cases where death is stated to have peen due to heart disease, the medical men had never seen the ises during life. In no heart cases is any attempt made note whether any objective signs of heart failure, e.g., dropsy, |ubbed nails, etc., were to be seen on the body. In one case, congestion of the lungs" was diagnosed post-mortem from eternal examination by a physician who had never seen the [an alive, but the secret of the process is not imparted. In one case, where a death occurrred in a public institution, id the patient had been ill several days without the doctor iving seen him, the jury are careful to state that " no blame to be attached to the authorities, but, on the contrary, they iserve praise for the good care they took of the deceased." All contraire, des louages pour leur bon proct'des a Vegard defunt.^^) This was certainly very considerate of the jury, kt politeness may be carried too far. [In the case of a woman who died 3uddenly, death should Irdly have been put down to heart disease wnen nothing )re definite than " oppression " had been complained of dur- life, although a doctor called in after death " h.^d no objec- In to believe " that she died of this favourite lethal agent [coroners' courts. The only reason seems to be that the lily were respectable people (des braves gens.) Something ^re tangible should be forthcoming as a proof of the cause of Ith when the imposing machinery of a Coroner's Court has je been set in motion, even in the case of the most respect- families. The same physician had equally little objection ibelieve the same thing in another case on equally slender >unds. f X I 16 In this matter of deterraininf» the caus^ of death, coroners are placed in a very difficult position, because the law does not require them to find out the exact cause, but merely to sec if a crime has been committed. To incur expense which j does not lead to the detection of crime is "^jsidered one of the i cardinal sins. That neighbours' testimony as to the character i and habits of the suddenly deceased is of great value in afford i ing what in law is called a " presumption '' against crime there i can be no doubt, and from study of the records I can testify to the great pains which our own coroner always takes to invest! t gate this side of the question. In all the records tl^ 3 foUowitij.' j points are carefully covered by the non-medical testimony : — g 1. Marks of violence absent. 2. No external signs of poisoning. 3. Deceased stated to have eaten and drank only those tl things taken without ill effect by others. 4. Deceased did not, from conversation or behaviour, lead h the friends to suppose that suicide was contemplated. h 5. Deceased not known to have enemies. a: Now, these points, important as they are, do not prove a gi natural death. The utmost interpretation which could be put " upon them is " death from unknown causes, without suspicion ai of crime." This is better than attributing the death to unspeci -^ fled " natural causes," and much better than ascribing it to ai ro imaginary heart disease which probably does not exist in tin of majority of cases. 8,i The laity always suspect poison when death is sudden, bu re the medical profession knows that but very few poisons exis po which can cause people to drop dead. The external evidenci pr of poisoning is usually absent, or at least has not been presen up in any of the four cases we have examined. Absence of state ^i ments as to intended suicide would not seem to be of mucl Ipi value, judging from the fact that in only one of the 12 cases ( Me suicide which have been investigated hau any statement bee! wo made by the victims of their intention. People who talk suicid v^ seldom commit suicide. The great disadvantage of all this sor of evidence is that it is mostly obtained from those who may h X ~V 17 ers (interested. As Coroner McMahon has often pointed out, peo- not )h\e in large cities know verj little about the doings of their see (jheighbors, the conditions being (juite different from those obtain- ich Jng in country places. When death from unknown causes the ^atis6es the ends of justice, well and good ; but for any iter ,|inore explicit cause of death it would be simpler, instead of try- »rd- ftng to exclude the many possible causes which are absent, to ere *nd out the one real cause. f to I We have a great admiration for juries in general, and admire sti- ;|he spirit of fairness invariably shown by our Canadian juries in ing 'Particular, when human interests are really at stake. Their - Sympathy for the wronged and unfortunate is worthy of all Iaise, and they stand in no awe of the corporations which press us, but as an institution for finding out causes of death 3y are not an unijualified success. When the cause of death is not clear without an autopsy we ve made it our practice simply to state that fact. This has d the result, not of an increased number of autopsies, but in increased number of deaths from unknown causes — presum- ly, visitation of (rod. We live in hopes that these numerous ^visitations of God " may tend to hasten a millenium when topsies will be more freijuent. The first and most important duty of the medical witness is ascertain the cause of death, and it is satisfactory to know that the 26 autopsies held the cause of death could be definitely ited in every case except three, two where the bodies had mained a long time in the water and become greatly decom- 3ed, and one shown to be due to poison. Even in these nn- ■omising cases, however, the important medico-legal points uld be determined at the autopsy. Presuming that the me precision as to the cause of death would have been tained in the remaining cases, we may assume that had antop- s been made at all the inquests about 1 80 deaths out of 201 uld have been satisfactorily explained. In 14 accidents, where external examinations only were Iflilowed, the cause of death could only be made out satisfactorily cr li ''III 6, 2 having broken necks, and 4 having the skulls completely £ 2 ' t; ■ ■ ■.' , .^ 18 crushed in. In the remainder we confined our statement III 1 I the fact that sufficiently severe external injuries existed to lie j compatible with the presence of fatal internal injuries not evident y from external examination. I j When no accident had taken place the external exarainatioii ^ gave almost uniformly negative results. In Itj such cases we i confined ourselvea to the statement that it was impossible to state the cause of death from the external examination, and that il the determination of the cause of death was necessary an autopsy n would have to be made. In no case did we make any attemi' « to guess at the probable cause. v In following strictly this rule we were guided by the princi ^ pies laid down by Brouardel, probably the greatest of all livin, d medico-legal experts, that the duty of the expert in medico-lega g{ cases is to state either that a certain fact is proved, or that i q is not proved, and to show sufficient facts in support of any con tl elusion drawn to make the testimony amount to a demonstration g Demonstrations, not opinions, are what is wanted. In no case i tf a witness in medico-legal cases justified ingiving his opinion un f( less he can support it by statements of acts which establish it tj correctness. The great reputation now enjoyed by the Frenci h; school of legal medicine is as much due to their strict adherenc jf to this principle as to the brilliancy of their methods and tli' n clearness of their logic. Unfortunately the necessity for this scientific attitude i ri not yet appreciated by many of those who give evidence be p fore coroners. If they do not know the cause of death they fee re bound to hazard a guess and appear to know all about ii gp Much of the loose medical evidence given before coroners al due to the pertinacity with which juries will persist in askin whether the cause of death may not probably or possibly be du oi to such and such a thing. If the least admission is made the igj will promptly render a verdict to that effect, for which the med fo: cal witness becomes virtually responsible, though fully awar \^ that there are a dozen other causes, any one of which may be th •^»| right one. The only resource of the medical witness is to refu? pg ^ to say more than is established by the facts which have con ti< in ■"^.-^ ^jji 19 ^^ ilnder his notice. lie is under no '• 'gation to say what miyhf '^ kaveltet^n, but only what wax the ea.e, if he can. " Of all sad ®"' %ords, the saddest are these — ' it ini^ht have been,' " when they ">ibrm part of medical evidence before coronerr ; and to this and '^^^ Anfoundod medical testimony rather than nei^loct of juries must ^^^ Be hold responsible for much that is regrettable in the past six ;ate jlionths' evidence. t 'I S We have wondered not a little in readin;; the records of in- P^J Iftiests why it is that medical witnesses so seldom make a written i^r' Sifttement of the facts which they observe, and of the conclusions iihich they have drawn from them. In the past six months, i^ci lipart from our own testimony, this does not appear to have been ^iif J#ne in a single instance ; and yet it would form the greatest Bga meguard a medical man could have against any future charge it i 'm giving a wrong opinion, as at any future time by consulting con Mq record it could be shown why that particular opinion was ;ion pven. This is the universal practice in other countries, and '*^ i' witnesses are obliged by law to state the facts upon which they "II flrm their opinions. There is no need for any reserve or hesi- 1 it: fpion in stating facts. Personally, in following this system we Jncl Mve found that time is saved and cross-examination shortened Jnc' iia written report is submitted. We can confidently recom- th( flfend this plan to others. a We constantly find that too little time is given to prepare a 5 i A)ort, because the jury has to meet at a certain time. In Ijf Mance a physician charged with an " expertise "' is given as a fee lae a week in which to prepare his report, unless the matter is t ii aBBcially urgent, and a clear 24 hours should certainly be rs i $fl|owed. kin #[t should be borne in mind that the medical opinion in an du «inary death certificate, where no grounds for suspicion ex- the MBd, is only needed for general statistical purposes, and there- Qed Me approximate accuracy in a large number of cases suffices. war afcere, on the other hand, suspicion of a crime exists, what is eth.|«ited is, as nearly as possible, absolute accuracy in the one 3fus Jpticular case. Slight inaccuracies in a mass of general statis- 300 Hkl information tend to correct themeelves. Serious inaccuracy ^fk single important criminal matter is quite inexcusable. ^■: * •■4. ii*' .^jf' 20 Great inconvenience \s caused by the absence of an otticiiil clerk or secretary to take notes of the autopsy, so that tbi' [)bysician coubl always (lescril)o aj)[)carances while they were before his eyes. In other countries this is always attended tn by a 8[)eciul olficial. A|)art frona the physical labour of writiti;: out a lonj; report, there is ^^^reat dan;^er that facts will be for gotten and error cree[) in if the memory is trusted to. Hesidi s this, in the act of descrij)tion new points are suggested for in vestigatioii which otherwise miiy be forgotten till it is too late. Another defect is the absence of any .system by which written instructions as to the nature of the information wanted is fur- nished the expert. In France and Germany a definite series of questions are asked the expert, and he thus knows what is expected of him and can give full information upon the vital points of the case. ( )IIiciaI regulations are also greatly needed as to the techniciue to be followed in making an autopsy. Were there any instructions as to the advisability of some of the clothes of the deceased being removed before the autopsy is con sidered finished, we should not recently have heard of under takers discovering bullet wounds unnoticed by the medical ex perts during their post-mortem. Another important matter is that arrangements should be made by which the expert shall see the body before it has been aj disturbed. In six months' work we have hardly seen a single oi body in the state and with the conditions and surroundings oc which existed at the time of death. It is almost always trans- in ported, undressed, placed in a coffin, or otherwise interfered b( with. In some instances embalming had even been done b) the undertaker. pi The chief complaint against the Coroner's Court in the past (J^ has been in regard to want of precision respecting the causes of ti( death assigned. We have seen that in the past six months a at material improvement in this respect has taken place, and a m larger number of the causes of death are supported by some (|( tangible evidence. This improvement, however, has been limited to those cases where autopsies have been performed, ju "^ and until this is done in every case where inquests are held it dl '^ i 21 not likely that tho verdicts of coroners' juries will be taken roprea(Mitirij^ the truth, the whole truth and nothini^ but the puth, about the deaths which they investigate. Apart from ■i'4ccidents attested to by eye-witnesses, about DO per cent, of all le cases coinin;^ before the coroner are cases of natural death, Ind without the control afforded by the results of post-inorteras and the counsel of a medical expert, it is not reasonable to #xpect a coroner having a lej^al trainin<^ only to estimate the fcmount of credence to be attached to all the diverse medical Evidence given in these cases. Taylor wrote, over thirty years llgo : " As a general rule, it may be stated that inquests in which there is no medical examination of the body are a vain llockery, and the sooner the public becomes imbued with that i^ea the better it will be for society." Whether this still holds )od ot Montreal inciuests may be judged from the results we ive given of the past six months' work. It is our ex[)erience that where an external or partial lamination only is made the results are nearly or (|uite value- js. Hence, in cases where no autopsy is performed the ^estigation cannot be regarded as a serious one from a medi- standpoint. •f, Although the number of autopsies held shows an increase compared with former years, yet, even now, in 200 inquests cftly 26 autopsies were held, or, in other words, only 12 per it. of the cases of suspicious deaths received serious medical ^estigation, although nominally over 200 examinations of the ly were made (and paid for.) |[It may be stated that in 76 cases of acccident, forming 38 cent, of the total, the death was obviously due Ifc an acci- it attested to by eye-witnesses, and that a medical examina- was superfluous. If it was superfluous, why was it made all ? If it was necessary, why was it not ordered to be le thoroughly ? Why is it that autopsies are often hurriedly le, " while you wait," because the jury are in a hurry ? jlt appears that further reform in this matter is urgently sessary, and we may conclude by mentioning briefly the jctions in wli^ch it shoold bo mcde : — /*' i 3 22 r^-^. 1. Autopsioa should be performed in all cases of suspicion or sudden death where the cause of death is douhtful. 2. The coro' T should be allowed to decide whether an autopsy is necessary, and to order it to be performed, if advi.s able, before the jury meet. (English co^^ners, under Vic. ;')() and 51, cap. 71, are allowed full discretion as to the orderin^^ of autopsies and the time when they shall be held.) 3. In medical testimony, the observed facts upon vhicli opinions are based should always be stated, preferably in writin;^. The improvement which has been effected already is a hope- ful indication for the future, and we hope in the report of the next six months' work to be able to show a decided advance over that of the past half year, which may be regarded in the li^lit of an experiment. X V . ,.« ... • »■ ■ J • I < . V ( ■ ( r .^ „s-^ .^ ■..•?*«>'' •