Observations on Coroners
Date: 2018-10-15T00:00:00+00:00
Keywords: Coroners -- Great Britain

The Project Gutenberg eBook of Observations on Coroners

This ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

Title: Observations on Coroners

Author: William Hewitt

Release date: October 15, 2018 [eBook #58104]

Language: English

Credits: Transcribed from the [1852] Samuel Daynes edition by David Price

*** START OF THE PROJECT GUTENBERG EBOOK OBSERVATIONS ON CORONERS ***

Transcribed from the [1852] Samuel Daynes edition by David Price, email ccx074@pglaf.org

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.

“The man returned home that day, and remained a week when he came again to me.  I called upon Mr. Webber and mentioned the ease of the poor man who had been to me, and handed to him the two notes I received from Mrs. Shirley on the subject.  Mr. Webber said he was exceedingly anxious to see the practice of Homæopathy, and if my remedies failed in removing the stone, he would be very glad to operate on the man, if I would allow him.  Accordingly on the morning of the man’s arrival to stop in Norwich, which was Wednesday, the 11th February, Mr. Webber accompanied me to his (Swann’s) lodgings, at Nurse Phillips’.  We sent the man up to his room, and desired him to prepare himself—Mr. Webber, myself, and the Nurse followed soon after.  I then attempted to introduce my sound into the man’s bladder—the one I had used before; on this occasion I found the instrument from being cold, seemed to be grasped by the uretha; I ordered the nurse to bring some warm water, with which I warmed another instrument and passed it through.  Upon Mr. Webber calling the attention of the jury to this expression, Dr. Bell said ‘I introduced it with the greatest facility.’  I immediately felt a stone, and I then passed the instrument to Mr. Webber, who said he felt it also.  He withdrew the instrument, and upon my solemn oath, not a particle of blood or sign of blood followed.  After the lapse of a minute or two, Mr. Webber drew an instrument of a large size from his pocket and introduced it, and he also injected some hot water.  (Mr. Webber here exclaimed ‘hot water.’)  On my oath, gentlemen, not hot water, but scalding water.  Directly after this instrument was withdrawn, the man left the house.  On my next visit, it was reported to me by the man and the nurse, that he had been parting with a good deal of blood, and I prescribed accordingly—I never introduced any instrument after that.  Every visit that I made afterwards, I found that the man became more and more dissatisfied—he said he was anxious to leave me and Mr. Webber and go home, and the nurse declared that Mr. Webber had injured the man by the injection.  Finding that he did not improve—that his nervous system was becoming more irritable, I called on Mr. Webber the following Wednesday morning, who observed I had done evil in bringing the man to that woman’s house, and we went and visited him.

“The days on which Mr. Webber saw him with me, were the 11th, the 18th, and the last time, the 22nd of February.  On these occasions, Mr. Webber spoke to me respecting my treatment, and that was the reason why the man’s confidence in me was removed—but this was not all—on the evening of Sunday, the 22nd, Mr. Webber visited the man when I was not with him; after doing so, he sent me a note, and here it is:—

Dear Sir,

Having since I parted from you, been again summoned to the neighbourhood of Crook’s Place, I took the opportunity of giving Swann another look, I saw no ground for altering the opinion I openly expressed to you at our meeting; nor will I suffer the real issue in the case, the security and welfare of the patient, to be prejudiced by irreconcileable and strange disclosures which have been made, reflecting most unfairly and ungenerously upon me, considering the candour and frankness I have shown towards you, but to which I shall not now further allude, the real object of this note, being in my estimation of far more importance than professional differences; therefore, let me again beg of you to lose no further time in pursuing those measures, of which you at our first meeting expressed yourself as “sceptical or doubtful,” but at once to adopt more energetic means for the relief of the sufferer.

Understand me, I do not mean for a moment to assert that the inflammation which you agreed existed, may not abate or be determined without the application of the leeches, &c., but surely the known sequelœ of neglected opportunity, such as ulceration, &c. ought to be thought of, and if possible, to be averted—they being as effects quite as mischievous in the end, as the cause—the inflammation itself; the only difference that I ever observed, being that the one destroys quicker than the other, but both as certainly.

The patient begged of me to write to Mrs. Shirley, and state the facts of the case, and I cannot deny his request; but I will “nothing extenuate or aught set down in malice.”

As you have admitted to me, that you occasionally give half-grain doses of opium and of quinine (allopathic doses,) as “homæopathic to disease” (?) excuse my ignorance, you will I apprehend, have no difficulty in carrying out sound constitutional treatment, with local means, in the case in point.

I am, Sir, yours in much haste,

W. WEBBER.

St. Giles’, Sunday, Feb. 22nd, 1852.
To Dr. Bell.

“This shows that Mr. Webber went in my absence and talked to the man.  I had told him to leave Swann in my hands, but instead of that, he visited him in my absence.  Up to that night, the nurse had invariably told me that it was the injection which had injured him, but after that, Mr. Webber and the nurse seemed to have set him against my treatment.  On Tuesday, the 24th, when I visited him, he would have nothing to do either with me or my medicine, and the nurse suggested that I should send for another medical man.

“On Wednesday morning, the nurse came to me, and asked me to see him early.  I went immediately to him, and found him labouring under a paroxysm of the stone.  He declined to receive any medicine from me.  The nurse then suggested that Mr. Webber should attend him—I was much surprised at this, as previously she had always abused Mr. Webber.  I asked the man if he wished Mr. Webber to see him, and he replied that he did.  About nine o’clock the same morning, I wrote to Mr. Webber, stating that the man refused to use my medicine, and that he wished to see him.  Mr. Webber sent me a note, stating that the wife of Swann had just been, and requested that he would take charge of her husband’s case, which he had promised to do.  The man after this remained five weeks in Norwich, during which I had nothing to do with him.”

The coroner commenced ordering strangers and witnesses to withdraw, previous to his summing up, when Mr. Webber asked the coroner why he had been summoned, and insisted on his right to be heard, after the palpably incorrect statements which Dr. Bell had been allowed to make—the coroner replied that he did not consider it was necessary for Mr. Webber to give evidence at all. [46]  The foreman of the jury, (Mr. Coleman) said “He thought it would be no more than right, that as Dr. Bell had made a statement, Mr. Webber should be allowed to make a statement also;” this opinion his brother jurors coincided in, and much against the inclination openly expressed, and the significence of great and frequent impatience of the coroner during the time occupied in the delivery of the evidence.  Mr. Webber, after being sworn, deposed as follows:

I am a M.R.C.S., Eng., residing in Norwich.  I received a note from Dr. Bell on the morning of the 11th of February, who asked at what time I could see a patient of his who had been sent by a lady, to be placed under his care, to which I returned an answer, and agreeably to arrangement, Dr. Bell called on me, and proceeding on our way to Mrs. Phillips’, in Union Place, he said he believed the patient, Wm. Swann had a stone in his bladder.  That Mr. John Coleby of North Walsham had examined him, but had not found one, and he therefore wished to be satisfied that he was correct in the opinion he had formed.  That he intended to treat him homæopathically, and that if the man should not be relieved by his treatment, about which he was “sceptical,” (“as he had had no experience in this disease”)—he would then hand him over to me to be operated upon, as he believed I was fond of operating in such cases—I told him I had no fondness for cutting up anybody, but, that when operations came in my way, and they were necessary, I never hesitated to perform them.  He said he was not in the habit himself of operating in such cases.  I agreed to go and examine the case, stating at the same time that I would have nothing to do with the treatment he proposed.  That if his system proved to be a sound one, I should not hesitate to proclaim it as a great boon to suffering humanity, but that if it should prove to be otherwise, he might rest assured I should expose it.

Arriving at Nurse Phillips’, I there saw Swann, who was a man about five feet, nine or ten inches in height, in tolerably fair plight, no emaciation, no evidence of extensive organic disease going on, nothing beyond a slight wearing from the irritation which generally accompanies stone in the bladder, and with nothing in his appearance to interdict an operation after a week or two preparation, nor to exclude the benefits of opportune and proper treatment.

It is usual when a consulting surgeon is called in, to allow him to perform the manipulation, but in this case Dr. Bell himself passed the sound—I stood by while he attempted to pass it, which in my opinion was of a very objectionable form, and such a one as he would be likely to experience difficulty in introducing, and not calculated to detect the stone when in.  On passing it down to the commencement of membranous portion of the urethra, he came to the check which I had anticipated; he then made forcible attempts to pass the instrument, despite my advice not to do so, conveyed in the words “Oh do not use force; pray do not use force—force will do no good, you will do harm.”  That instrument was withdrawn, but not until force had been used.  Another and smaller instrument was tried by him, when the nurse suggested that he had better use some warm water, as she thought the instrument might be cold, and she brought some.  A further attempt was made to pass the instrument, and more force was applied, and Swann cried out “Oh! sir, you have hurt me, it has gone somewhere, I think it has gone wrong,” of which, I myself, entertained no doubt.  The instrument was then partially withdrawn, and I seeing where the difficulty existed, recommended that this sound (producing it [49]) should be passed instead, for it had never fallen to my lot to see such unskilful manipulation as was exhibited by Dr. Bell, whose hand shook considerably at the time.  He then turned the instrument and effected an entrance into the bladder.  He said he felt the stone, and requested me to take the instrument, I did so, and felt a grating, but not being satisfied, I requested him to withdraw his instrument and I would introduce mine.  I have no doubt that the urethra had been lacerated, for on his withdrawing his instrument, blood dropped on my boot.  I do not say there was any great quantity, nor was it likely there would be, because it became extravasated; therefore, I adopted my usual plan in such cases, which was to introduce an instrument as large as the passage.  I passed the instrument into the bladder and struck the stone, and I believe the sound was audible to the nurse, who is accustomed to such cases.  Dr. Bell not being satisfied, on this, I withdrew the sound, and proceeded to inject into the bladder tepid water, as no surgeon in his senses would do what Dr. Bell states I did—use hot water, and if he would, he could not, for the patient would not let him.  I then handed the instrument to Dr. Bell and turned the stop cock, allowing water to run out, so that the stone might fall on the end of it which it did, and was heard distinctly by those present, and Dr. Bell having assured me he felt it distinctly, it was withdrawn.  During the progress of the examination, I asked the man whether he felt any serious pain, and he said, “I hope you have done, for I am getting very faint.”  As he was very deaf, I put the question to him again, and asked him, did the last instrument hurt you? and he said “No; the last instrument did not hurt me.”  All this was done openly.  Dr. Bell said he was going to treat the man homæopathically; I said “he might do as he pleased, he might humbug the patient, but that he should not humbug me, and I would have nothing to do with such treatment.”  Dr. Bell then mixed some medicine in some water in a tumbler glass; it did not readily dissolve, and he called for another tumbler, and in order to dissolve it, he poured the contents of one tumbler into another several times, and in the process, spilled one half of it.  Thus showing how important these medicines are in their integrity.  It was arranged that if the man was not benefitted at the end of a month, he should pass into my hands to be operated upon.  I remarked to him that that time would afford no criterion of the value of his treatment, as patients had what is called fits of the stone, and if the fit went off, he would take the credit of curing the man, when in fact he had done no such thing.  Dr. Bell states that I saw the man on Wednesday, the 18th, but that is not correct, as on that day I was called to and attended a patient in Cambridgeshire.  On the following Sunday, (the 22nd,) he came to me and asked me if I had seen the man again, I replied certainly not—he asked me if I would come and look at him, because said he, “my treatment does not appear to succeed with him, I have no great confidence in its success.”  I went with him to nurse Phillips’, and never in my life did I behold a man so changed—his condition was that of a man suffering under acute inflammation.  I immediately turned up the bed clothes, or rather the sheet, and placing my hand lightly on the body, I was about to examine the state of the bladder, when he shrieked violently, saying “Oh! take away your hand, sir—I cannot bear it—you will kill me!”  I had used no pressure.  I then turned round and said, “Dr. Bell, how comes this about?  Why the man has got inflammation of his bladder, what have you been doing?”  The man was rather deaf, but he caught the last words, and looking at Dr. Bell, said “you have done it; you have given me poison.”  Dr. Bell remarked, “I have merely given him nux, [52] because his bowels were confined.”  I then said “there is no time to be lost; I fear the man will die; you had better put on leeches, as soon as you can, and have recourse to fomentation, and the sooner the better,” when Dr. Bell remarked “Can we not go some where else and talk?”  I said “No, sir, whatever I do every body is welcome to see and hear, I will be a party to nothing in the dark, and I will tell you, unless you stop this inflammation soon, it will soon stop the man.”  Dr. Bell said “that he would not take a drop of blood from the man, and he mentioned the names of several persons who, he said, knew the cause of inflammation, and that it could be stopped without it.”  Being called into that neighbourhood on the evening of the same day to attend a patient of my own; and being anxious about the poor fellow, I called again at Mrs. Phillips’, but did not see the deceased.  The nurse said that she had used fomentation, but the man was in great pain; I asked if Dr. Bell was there, and on her replying that he was not, I said I would write to him, (and hence the letter which Dr. Bell has thought proper to produce in his defence.)  I then took my leave—Dr. Bell continued to attend him, on the Monday and Tuesday, and on the Wednesday, I received a note from him, asking me when I could attend, but I did not immediately answer it, as I saw his motive for writing in such a way.  After this, Swann’s wife called upon me and I did attend, and I found the man discharging mucous from every mucous surface.  Mr. Crickmay who happened to be in my house at the time went with me, and also saw the deceased, and he enquired as to the remedies that had been adopted; we both thought the man was sinking—his pulse was almost imperceptible at the wrist—his eye was vacant—the surface of his skin was clammy, and there were other indications of that general decline of power which frequently precedes death.  I naturally inquired what the man had been taking, but before the nurse could answer, he said “he has been giving me more poison, I know it was arsenic, because I have mixed arsenic and lime with wheat, and know the smell and taste too.”  This is the condition I found him in—I prescribed for him, directing such treatment as I conceived to be required to meet the exigencies of the case.  He continued much in the same state for four or five days, the principal symptoms being diarrhoea, and a discharge of a small quantity of urine, mixed with bloody mucous and pus, which he had great difficulty in voiding.  He then rallied somewhat, but relapsed in a day or two, and fearing the threatened result, and being influenced by the remarks being made out of doors, which were loud and condemnatory of the treatment the man had received from Dr. Bell, I thought it necessary to call in Mr. Gibson, a medical man, with whom I was not intimate.  On the evening on which Mr. Gibson saw the man, he supported him while I drew off his water, and after Mr. Gibson had examined him, he came to the same conclusion as myself, that abscesses were forming in the neck of the bladder, and in the tissues connecting that organ with the adjacent structures.  Mr. Gibson said that he had nothing to suggest in addition to my treatment.  He saw the man the next day, and he said there was evidence of abscesses having burst, both in the rectum and in the urethra, for a great deal of pus had escaped.  For a few days the man rallied again, but we had no hope for him at that time; and those who understand these cases, will tell you, that when abscesses form, as the result of injury and irritation in structures adjacent to the bladder and its connections, they will, by a continuous irritation in the absence of controul, lead to the perpetuation or encroachment of similar action in similar tissues, as for instance, an abscess in the capsule of the kidney, which has been attested to by Mr. John Coleby as the proximate cause of death. [55]  From that time however, the man gradually progressed, and thanks to good watching, good nursing, and a generous diet, he recovered sufficiently to be removed home, not with my consent, but from frequent importunities I submitted to his going home, and he having improved, to a certain extent, I told him that he was at liberty to please himself, as to the future; he could either be under Mr. Coleby’s care, or he might return to me, and he went home on the 30th of March.  I heard no more of him for a fortnight, when he sent word to me he was going on well, and that he hoped to return to undergo the operation.  From the cause before mentioned, and possibly owing to the less nutritious diet, another abscess formed—after this, it appears the vital powers began to sink.”

Dr. Bell declined cross-examining Mr. Webber, and no other evidence being called, the room was then cleared of strangers and witnesses, and the jury proceeded to consider their verdict; after deliberating about 20 minutes, the foreman returned the following verdict:—“That William Swann died from an abscess in the capsule of the left bladder,” but on the suggestion of Mr. Crickmay, the coroner substituted the word “kidney” for “bladder,” remarking that, that was what the jury intended.  One of the jury said that the foreman had not given the verdict exactly as agreed upon; and the foreman then added the words “and we are of opinion that deceased’s death was accelerated by improper treatment.” [56]  Mr. Crickmay said, by whom do you consider improper treatment was used?  The coroner observed “as for that, you and the public are to form your own judgment.”

Thus terminated a painful enquiry, on which a large volume might be written in behalf of humanity, expressing regret, for the sufferings of the unfortunate deceased—expressing regret that his care, his counsel, and his regard shown to his wife and children should be so untimely lost—expressing regret that the good intentions of Mrs. Shirley should apparently, through misplaced confidence, be frustrated—expressing regret, that a professional gentleman standing in this case in an awkward position, should make a more awkward defence, in apparently endeavouring to cast the blame on others, who wholly undeserved it—expressing regret that a member of the Royal College of Surgeons, in Ireland, [57a] who is supposed to possess an acquaintance with the tissues and structures of the human body, apparently forgot that the larger an instrument, called a sound, can enter a canal at a given part, the less danger there is of rupturing a tube, or wounding a delicate membrane.  But above all, expressing regret, that having apparently neglected the precaution given by Mr. Webber not to use force; having witnessed the agony accompanying inflammatory action which followed, he persisted to combat it by such apparently vague medical treatment. [57b]  For this it appears was nearly sending Swann to a still earlier grave.  His life, however was for a time preserved through the skill and perseverance of Mr. Webber, and the great attention Mrs. Phillips, the nurse, paid to the deceased.  But the days of the poor agricultural labourer were numbered; and his earthly sufferings having ceased, an earnest hope may be expressed that his ethereal spirit—his soul, may be now slumbering in the bosom of his Father, and his God.

The cases narrated, plainly demonstrate that care, tact, delicacy, and discernment, are required at coroners’ inquests—for a two-fold object must be kept in view:—the one to ascertain the proximate cause of death, whether arising from natural or mechanical events, and the other, whether the law can take cognizance of, and bring to justice the incautious, the ill-disposed, and possibly the gross offender against the laws of his country.

To the departed, these duties are of little moment, but to the living, they demand the greatest attention, not the less owing to the voice of humanity towards the friends of the deceased than to individuals, who innocent or guilty, may be directly or indirectly, suspected or implicated, in conniving or hastening, the death of a fellow creature.

It may be inferred, that jurymen [58] ought to assert their right [59a] (whilst the memories of learned coroners are sleeping) to ask questions, necessary to obtain evidence, that their minds may be so enlightened, as to record just and complete verdicts, even in Mala Praxis, for why should truth be withheld, when the Science of Medicine, with sound surgery for its helpmate, are being sullied in glory?

But it must be borne in mind, that a jury of men labouring in other vocations, living in a remote village, seldom attending coroners’ inquests, whose education is so limited, as not to be competent to seek for information, which the knowledge of medical jurisprudence inculcates, are the reasons why they must and do rely on the coroner to extract the evidence required; that their ideas of right and wrong may rest on the solid foundation of truth itself, which cannot be effected, unless the judge on obtaining evidence, explains the law bearing on the question, and introduces both, suitably to their comprehension. [59b]

Unless this object is realized, coroners’ inquests are perfectly useless, and evidently prove there must be something “rotten in the state of Denmark,” which if enquired into, will be found to prevail in many instances even where gentlemen in the legal profession are coroners.  But how can it be otherwise?  Their knowledge of medical jurisprudence, if to a certain extent comprehended, must be far too limited to conduct enquiries of grave importance.  The want of sound medical knowledge must prove the hindrance, because it is frequently observed when medical gentlemen give evidence, they use technicalities employed in the profession, and by stepping into details, they bewilder their hearers, and sometimes themselves also. [60]  Therefore it may be assumed, that great tact and discrimination is required in the examination in any case where medical evidence is of paramount importance, and consequently it may be believed, that unless gentlemen are properly educated, so as to be able to elicit important truths connected with the science of medicine in all its branches, as well as the legal points in coronership, they cannot be capable of conducting inquiries, in all the integrity, which these solemn occasions demand.

In conclusion, the following queries may not be deemed impertinent or superfluous:—

Is it customary for coroners to be petulant, irascible, and over desirous to close their enquiries?

Is it customary for witnesses to omit signing the depositions of their evidences?

Is it customary for coroners to allow disputations to exist in their presence, which do not appear to harmonize with the solemn character of coroners’ courts?

Is it customary with coroners to omit calling evidence that might be material towards corroborating testimonies where conflicting evidences arise, or links in the chain of evidence are broken?

Is it customary for coroners previous to summing up, to order their courts to be cleared of witnesses, strangers, and reporters, who had been admitted to hear the evidence?

Is it customary for coroners to summon witnesses in person, especially in cases of adjournment, where grave evidence has previously been given on oath?

Is it customary for coroners at adjourned inquests, to call upon parties, in person, suspected of felony, to inform them of it?

Is it customary for coroners to allow suspected parties present at inquests, to hold earnest conversation with jurymen, during enquiry?

In inquests of grave importance, is it advisable for coroners to summon jurymen all of one parish, especially if the jurymen are directly or indirectly connected with parties accessory before the facts, in cases of suspected felony?

If coroners doubt the veracity of a medical witness, and they state their reasons for doing so, are they not bound to suggest to the jury the propriety of calling other medical witnesses?

Is it customary for coroners to omit to recapitulate the evidence at the summing up, and neglect to explain the bearings of the law upon the various issues?

Is it customary for coroners to dictate verdicts, instead of leaving juries to come to their own unbiassed, deliberate, and honest conclusions?

S. DAYNES, PRINTER, NORWICH.

ADVERTISEMENT.

BY THE SAME AUTHOR:
ABOUT TO BE PUBLISHED BY SUBSCRIPTION,
UNDER DISTINGUISHED PATRONAGE.

Revised and considerably enlarged, a Second Edition of

AN ESSAY
ON THE
ENCROACHMENTS OF THE GERMAN OCEAN,
WITH A
Design to arrest its further depredations, applicable to the
Norfolk and other Coasts, by taking every particular
respecting them into consideration.

The Work will be interspersed with elaborate drawings of Cromer, Hasborough, &c., accompanied with diagrams, showing the full extent and meaning of the author, who, owing to repeated solicitation to introduce another Edition, and having obtained valuable and more ample information, announces his intention to comply, believing that this important subject may yet become, as it ought to do, a matter for national attention, and national expense.

The interested therefore are respectfully informed, that if they coincide in the desire they expressed, and the offer proposed, orders must be sent as early as possible, direct to the author, North Walsham, Norfolk.

The Work will be published in Royal quarto.

Price to Subscribers, £1 1s. 0d.—Non Subscribers, £2 2s. 0d.

OPINIONS of the PRESS on the FIRST EDITION.

“The work is another interesting addition to Norfolk literature, and the plan for the conservation of our Northern shores, is worthy attention, as coming from a gentleman, who, to some experience at least, adds the claim of having paid considerable attention to a subject of no little importance to the Northern and Eastern districts of the County.”

Norwich Mercury.

“The subject of this Essay is indeed of prime importance—First in a national point of view, as embracing particularly the interest of the public, and concerning in the closest manner the preservation of all the property of individuals situated on the contour of the coast of Norfolk, from the North Westerly point at Wells, to the Haven of Great Yarmouth.

“The main object of the enquiry is to discover the best plan of restraining the ravages of the sea, during the periods of extraordinary high tides; and on this point we entirely agree with Mr. Hewitt’s general view, and are strongly inclined to believe that it will answer in most cases where it may be judiciously carried into effect”

Norfolk News.

“The publication of this volume may be considered well timed.  It contains much information respecting the tides and currents of the ocean—the formation of the Norfolk Coast—the damage done by irruptions of the sea, &c.  We are no engineers, therefore we do not pretend to pronounce upon the merits of Mr. Hewitt’s plan for the construction of jetties, breakwaters, &c.; but it appears feasible, and merits the consideration of those whose property has been, and is threatened to be injured by the incursions of the ocean.  And we consider the work (which is dedicated to the Lords of the Admiralty,) to be creditable to the industry of the Author.”

Norfolk Chronicle.

“The author is a gentleman, whose profession (a surgeon,) could hardly be supposed to allow him much time to devote to a subject such earnest thought and investigation, as the one he has here attacked.  Mr. Hewitt, however, has evidently applied himself to this question con amore, and the work now before us evinces that he has brought to its consideration, a mind capable of patient and careful research into the many and varied causes that bear upon it.  Though undertaken more especially with a view to searching out and propounding a remedy for the locality of which it immediately treats, a considerable portion of the work refers to the Encroachments of the Ocean generally, upon all exposed points of the coast, and there is much in it that would apply to the Southern, as forcibly as to the Eastern coast

“Mr. Hewitt describes the plan which he recommends as the best mode of imposing a check to the Encroachments of the Ocean, and shows the supposed elevation of the beach from the deposit of sand likely to be caused by the inventor’s plan.

“The work is written in an earnest, but modest and unpretending style, and the aim of the author is so good and praiseworthy, that should it fail to make the impression on head quarters, desired by its writer, he will, under all circumstances, have the satisfaction of feeling that he has laboured in a good cause.  While other minds may perhaps entertain different views as to the utility or practicability of his scheme, they cannot fail to admit Mr. Hewitt deserves the thanks of his country, for the benevolent motives which have actuated, and the patient and diligent care which has directed his efforts in the field in which he has thus become a labourer.”

Sussex Advertiser, and Surrey Gazette.

“A remarkable ‘Essay’ which has met with the usual attention bestowed upon Cassandric warnings.”

Dickens’ Household Words.

FOOTNOTES.

[7]  Those havens that lie towards France, and have been thought by our kings to be such as ought most vigilantly to be observed against invasion.  In which respect, the places where they have a special governor or keeper, called by his office, Lord Warden of the Cinque Ports; and various privileges granted to them, as a particular jurisdiction; their Warden have an authority among them, and sending out writs in his own name.  The Ports are Dover, Sandwich, Rye, Hastings, Winchelsea, Romney and Hithe.  Some of which as the number exceeds five, must either be added to the first institution by some later grant or accounted as appendant to some of the rest.

[17]  Vide Sewell, on the Law of Coroners.

[28]  What were the tests applied, to prove that Laudanum had been administered to the infant?  If the child did not die from the effects of Laudanum, what caused its death?

[32]  Lord Lyndhurst, in a recent case, laid down the following rule:—

“In these cases there is no difference between a licensed physician or surgeon, and a person acting as physician or surgeon without license.  In either case, if a party having a competent degree of skill and knowledge, makes an accidental mistake in the treatment of a patient, through which mistake death ensues, he is not thereby guilty of manslaughter.”

“But if where proper medical assistance can be had, a person totally ignorant of the science of medicine—takes on himself a violent and dangerous remedy to one labouring under disease, and death ensues in consequence of that dangerous remedy having been so administered, then he is guilty of manslaughter; or a man may be guilty of manslaughter if, notwithstanding he has a competent knowledge of medicine, he be guilty of gross rashness in the application of a remedy or gross negligence in attending his patient afterwards.  Also, where a man doing a lawful act, which is at the same time dangerous, he neglects to use proper caution, death ensues, if it takes place within a twelve month and a day; but if his life exceeds that period, the law will presume that his death proceeded from some other cause than the wound.”—1 Hawk, P. C. 23 s. 90.

“If a man be sick of a disease which in all likelihoods would terminate his life, and another give him a wound or hurt which hastens his death, this is such a killing as would constitute murder.”—See 1 Lord Hale, 428.—Vide Sewell, on the Law of Coroners.

[39]  A term given to a fluid attending suppuration, one of the consequences of inflammatory action.

[46]  In the course of the enquiry, the coroner remarked he did not know who might have got up that inquest, and that had he been apprised of it, he should have appointed some person unacquainted with the deceased and the circumstances, to have made the post mortem examination.  Mr. Webber observed, “Sir, you cannot be in doubt upon that score, as you must admit, on the 15th of May, I enclosed you a note from Mr. Pilgrim, your brother coroner, to whom, supposing him to have been the coroner for the district, I mentioned all the circumstances connected with the deceased, and he conceived it was a proper case, in justice to all parties, that an inquiry should take place; and sir, I apprehend I have done your friend, on your left, no injustice, by getting his own friend Mr. Coleby to examine the body, for you cannot suppose, that the very cordial manner in which you saw Mr. Coleby shake Dr. Bell by the hand, he could have had any unfair or ill feeling towards him.”

[49]  This was a new instrument, admirably adapted for the detection of stone, lately invented by Mr. Webber, and manufactured by Ferguson, of Smithfield.

[52]  Nux.  Nux Vomica Strichnia.  This is a well-known remedy as a theraputic agent in cases of paralysis.  If this, or other medicines used by Dr. Bell, aggravated the misery of the sufferer, possibly that gentleman, who it appears was educated in the Allopathic School, might have used them in larger doses than is prescribed by a real disciple of the German Hahnemann.  Be this as it may, it furnishes a precious example to those who follow such vague practise in grave disease, where the life of the afflicted verges on eternity.  Yet, surely, none but vain and ignorant people, assumed or real, can believe in the shadow of a shade, though introduced with all the seductive novelty which specious artifice and subtle ingenuity can devise, as promulgated in the doctrines of a visionary enthusiast and his followers.

[55]  Metastasis or translation of disease frequently takes place at a remote distance from the original seat of mischief, involving tissues belonging to vital organs, and the afflicted sink through inanition or loss of vital power.

[56]  A verdict is altogether a matter of substance.  All the facts and circumstances must be stated with certainty and precision, without any repugnancy or inconsistency; and where it contains a charge, the charge must be direct and positive.—Vide Sewell on the Law of Coroners.

[57a]  So stated in the Medical Directory.

[57b]  This forms the nucleus for other observations, at a convenient opportunity.

[58]  The jury are to inquire into and judge of all matters of fact connected with the death of a party, and in certain cases of flight, forfeiture, deodands, &c. and for that purpose to receive such evidence as may appear necessary.  But they may give a verdict without testimony, where they themselves have cognizance of the fact; but if they give a verdict on their own knowledge, they ought to inform the court so.  They may however be sworn as witnesses, and the fair way is to tell the court before they are sworn, that they have evidence to give.

[59a]  According to Lyttleton, in which opinion Lord Coke concurs, if the jury will take upon themselves the knowledge of the law, the coroner is bound to accept the presentment which the jury make.

[59b]  But it appears (and very judiciously so) that the immediate and direct right of deciding upon questions of law is entrusted to the court, while in the jury, it is at most only incidental; that in the exercise of this incidental right, the latter are not only placed under the superintendence of the former, but in some degree controllable by them; and therefore, that in all points of law during an investigation, the jury ought to show the most respectful deference to the advice and recommendation of the court.—Vide Sewell on the law of coroners.

[60]  Each Art and Science has its technicalities, which must be used to designate the component parts severally connected with a whole.  Therefore, if hearers, particularly judges, do not understand evidence minutely given by medical gentlemen: the latter become confused, owing to using language perfectly comprehensible to themselves, but provokingly incomprehensible to others.

*** END OF THE PROJECT GUTENBERG EBOOK OBSERVATIONS ON CORONERS ***

Updated editions will replace the previous one—the old editions will be renamed.

Creating the works from print editions not protected by U.S. copyright law means that no one owns a United States copyright in these works, so the Foundation (and you!) can copy and distribute it in the United States without permission and without paying copyright royalties. Special rules, set forth in the General Terms of Use part of this license, apply to copying and distributing Project Gutenberg™ electronic works to protect the PROJECT GUTENBERG™ concept and trademark. Project Gutenberg is a registered trademark, and may not be used if you charge for an eBook, except by following the terms of the trademark license, including paying royalties for use of the Project Gutenberg trademark. If you do not charge anything for copies of this eBook, complying with the trademark license is very easy. You may use this eBook for nearly any purpose such as creation of derivative works, reports, performances and research. Project Gutenberg eBooks may be modified and printed and given away—you may do practically ANYTHING in the United States with eBooks not protected by U.S. copyright law. Redistribution is subject to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE

PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free distribution of electronic works, by using or distributing this work (or any other work associated in any way with the phrase “Project Gutenberg”), you agree to comply with all the terms of the Full Project Gutenberg™ License available with this file or online at www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project Gutenberg™ electronic works

1.A. By reading or using any part of this Project Gutenberg™ electronic work, you indicate that you have read, understand, agree to and accept all the terms of this license and intellectual property (trademark/copyright) agreement. If you do not agree to abide by all the terms of this agreement, you must cease using and return or destroy all copies of Project Gutenberg™ electronic works in your possession. If you paid a fee for obtaining a copy of or access to a Project Gutenberg™ electronic work and you do not agree to be bound by the terms of this agreement, you may obtain a refund from the person or entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be used on or associated in any way with an electronic work by people who agree to be bound by the terms of this agreement. There are a few things that you can do with most Project Gutenberg™ electronic works even without complying with the full terms of this agreement. See paragraph 1.C below. There are a lot of things you can do with Project Gutenberg™ electronic works if you follow the terms of this agreement and help preserve free future access to Project Gutenberg™ electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation (“the Foundation” or PGLAF), owns a compilation copyright in the collection of Project Gutenberg™ electronic works. Nearly all the individual works in the collection are in the public domain in the United States. If an individual work is unprotected by copyright law in the United States and you are located in the United States, we do not claim a right to prevent you from copying, distributing, performing, displaying or creating derivative works based on the work as long as all references to Project Gutenberg are removed. Of course, we hope that you will support the Project Gutenberg™ mission of promoting free access to electronic works by freely sharing Project Gutenberg™ works in compliance with the terms of this agreement for keeping the Project Gutenberg™ name associated with the work. You can easily comply with the terms of this agreement by keeping this work in the same format with its attached full Project Gutenberg™ License when you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern what you can do with this work. Copyright laws in most countries are in a constant state of change. If you are outside the United States, check the laws of your country in addition to the terms of this agreement before downloading, copying, displaying, performing, distributing or creating derivative works based on this work or any other Project Gutenberg™ work. The Foundation makes no representations concerning the copyright status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other immediate access to, the full Project Gutenberg™ License must appear prominently whenever any copy of a Project Gutenberg™ work (any work on which the phrase “Project Gutenberg” appears, or with which the phrase “Project Gutenberg” is associated) is accessed, displayed, performed, viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived from texts not protected by U.S. copyright law (does not contain a notice indicating that it is posted with permission of the copyright holder), the work can be copied and distributed to anyone in the United States without paying any fees or charges. If you are redistributing or providing access to a work with the phrase “Project Gutenberg” associated with or appearing on the work, you must comply either with the requirements of paragraphs 1.E.1 through 1.E.7 or obtain permission for the use of the work and the Project Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted with the permission of the copyright holder, your use and distribution must comply with both paragraphs 1.E.1 through 1.E.7 and any additional terms imposed by the copyright holder. Additional terms will be linked to the Project Gutenberg™ License for all works posted with the permission of the copyright holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg™ License terms from this work, or any files containing a part of this work or any other work associated with Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this electronic work, or any part of this electronic work, without prominently displaying the sentence set forth in paragraph 1.E.1 with active links or immediate access to the full terms of the Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary, compressed, marked up, nonproprietary or proprietary form, including any word processing or hypertext form. However, if you provide access to or distribute copies of a Project Gutenberg™ work in a format other than “Plain Vanilla ASCII” or other format used in the official version posted on the official Project Gutenberg™ website (www.gutenberg.org), you must, at no additional cost, fee or expense to the user, provide a copy, a means of exporting a copy, or a means of obtaining a copy upon request, of the work in its original “Plain Vanilla ASCII” or other form. Any alternate format must include the full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying, performing, copying or distributing any Project Gutenberg™ works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing access to or distributing Project Gutenberg™ electronic works provided that:

- • You pay a royalty fee of 20% of the gross profits you derive from the use of Project Gutenberg™ works calculated using the method you already use to calculate your applicable taxes. The fee is owed to the owner of the Project Gutenberg™ trademark, but he has agreed to donate royalties under this paragraph to the Project Gutenberg Literary Archive Foundation. Royalty payments must be paid within 60 days following each date on which you prepare (or are legally required to prepare) your periodic tax returns. Royalty payments should be clearly marked as such and sent to the Project Gutenberg Literary Archive Foundation at the address specified in Section 4, “Information about donations to the Project Gutenberg Literary Archive Foundation.”

- • You provide a full refund of any money paid by a user who notifies you in writing (or by e-mail) within 30 days of receipt that s/he does not agree to the terms of the full Project Gutenberg™ License. You must require such a user to return or destroy all copies of the works possessed in a physical medium and discontinue all use of and all access to other copies of Project Gutenberg™ works.

- • You provide, in accordance with paragraph 1.F.3, a full refund of any money paid for a work or a replacement copy, if a defect in the electronic work is discovered and reported to you within 90 days of receipt of the work.

- • You comply with all other terms of this agreement for free distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™ electronic work or group of works on different terms than are set forth in this agreement, you must obtain permission in writing from the Project Gutenberg Literary Archive Foundation, the manager of the Project Gutenberg™ trademark. Contact the Foundation as set forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable effort to identify, do copyright research on, transcribe and proofread works not protected by U.S. copyright law in creating the Project Gutenberg™ collection. Despite these efforts, Project Gutenberg™ electronic works, and the medium on which they may be stored, may contain “Defects,” such as, but not limited to, incomplete, inaccurate or corrupt data, transcription errors, a copyright or other intellectual property infringement, a defective or damaged disk or other medium, a computer virus, or computer codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right of Replacement or Refund” described in paragraph 1.F.3, the Project Gutenberg Literary Archive Foundation, the owner of the Project Gutenberg™ trademark, and any other party distributing a Project Gutenberg™ electronic work under this agreement, disclaim all liability to you for damages, costs and expenses, including legal fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a defect in this electronic work within 90 days of receiving it, you can receive a refund of the money (if any) you paid for it by sending a written explanation to the person you received the work from. If you received the work on a physical medium, you must return the medium with your written explanation. The person or entity that provided you with the defective work may elect to provide a replacement copy in lieu of a refund. If you received the work electronically, the person or entity providing it to you may choose to give you a second opportunity to receive the work electronically in lieu of a refund. If the second copy is also defective, you may demand a refund in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied warranties or the exclusion or limitation of certain types of damages. If any disclaimer or limitation set forth in this agreement violates the law of the state applicable to this agreement, the agreement shall be interpreted to make the maximum disclaimer or limitation permitted by the applicable state law. The invalidity or unenforceability of any provision of this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the trademark owner, any agent or employee of the Foundation, anyone providing copies of Project Gutenberg™ electronic works in accordance with this agreement, and any volunteers associated with the production, promotion and distribution of Project Gutenberg™ electronic works, harmless from all liability, costs and expenses, including legal fees, that arise directly or indirectly from any of the following which you do or cause to occur: (a) distribution of this or any Project Gutenberg™ work, (b) alteration, modification, or additions or deletions to any Project Gutenberg™ work, and (c) any Defect you cause.

Section 2. Information about the Mission of Project Gutenberg™

Project Gutenberg™ is synonymous with the free distribution of electronic works in formats readable by the widest variety of computers including obsolete, old, middle-aged and new computers. It exists because of the efforts of hundreds of volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the assistance they need are critical to reaching Project Gutenberg™’s goals and ensuring that the Project Gutenberg™ collection will remain freely available for generations to come. In 2001, the Project Gutenberg Literary Archive Foundation was created to provide a secure and permanent future for Project Gutenberg™ and future generations. To learn more about the Project Gutenberg Literary Archive Foundation and how your efforts and donations can help, see Sections 3 and 4 and the Foundation information page at www.gutenberg.org.

Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non-profit 501(c)(3) educational corporation organized under the laws of the state of Mississippi and granted tax exempt status by the Internal Revenue Service. The Foundation’s EIN or federal tax identification number is 64-6221541. Contributions to the Project Gutenberg Literary Archive Foundation are tax deductible to the full extent permitted by U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up to date contact information can be found at the Foundation’s website and official page at www.gutenberg.org/contact

Section 4. Information about Donations to the Project Gutenberg Literary Archive Foundation

Project Gutenberg™ depends upon and cannot survive without widespread public support and donations to carry out its mission of increasing the number of public domain and licensed works that can be freely distributed in machine-readable form accessible by the widest array of equipment including outdated equipment. Many small donations ($1 to $5,000) are particularly important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws regulating charities and charitable donations in all 50 states of the United States. Compliance requirements are not uniform and it takes a considerable effort, much paperwork and many fees to meet and keep up with these requirements. We do not solicit donations in locations where we have not received written confirmation of compliance. To SEND DONATIONS or determine the status of compliance for any particular state visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where we have not met the solicitation requirements, we know of no prohibition against accepting unsolicited donations from donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot make any statements concerning tax treatment of donations received from outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation methods and addresses. Donations are accepted in a number of other ways including checks, online payments and credit card donations. To donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project Gutenberg™ electronic works

Professor Michael S. Hart was the originator of the Project Gutenberg™ concept of a library of electronic works that could be freely shared with anyone. For forty years, he produced and distributed Project Gutenberg™ eBooks with only a loose network of volunteer support.

Project Gutenberg™ eBooks are often created from several printed editions, all of which are confirmed as not protected by copyright in the U.S. unless a copyright notice is included. Thus, we do not necessarily keep eBooks in compliance with any particular paper edition.

Most people start at our website which has the main PG search facility: www.gutenberg.org.

This website includes information about Project Gutenberg™, including how to make donations to the Project Gutenberg Literary Archive Foundation, how to help produce our new eBooks, and how to subscribe to our email newsletter to hear about new eBooks.

back

back

Table of Contents

- OBSERVATIONS ON CORONERS,

- To the Right Honourable The Secretary of State, for the Home Department.

- OBSERVATIONS ON CORONERS.

- ADVERTISEMENT.

- OPINIONS of the PRESS on the FIRST EDITION.

- FOOTNOTES.

- THE FULL PROJECT GUTENBERG LICENSE