SIX MONTHS' MEDICAL EVIDENCE 
IN THE 
CORONER'S COURT OF MONTREAL. 
BY 
WYATT JOHNSTON, M.D., Montreal, 
AND 
GEORGE VILLENEUVE, M.D., Montreal. 
(Reprinted from the Montreal Medical Journal, August, 1893.) SIX MONTHS' MEDICAL EVIDENCE IN THE 
CORONER'S COURT OF MONTREAL 
(January to June, 1893).* 
By Wyatt Johnston, M.D., 
Montreal? 
and 
George Villeneuve, M.D., 
Montreal. 
At the commencement of the present year, when, on account 
of his long experience in criminal matters, our present energetic 
and capable coroner was appointed, it was intended that his 
duties were to be purely judicial, and that medical questions in 
connection with coroners' inquests were to be investigated by a 
physician specially appointed for that purpose, whose duties 
should correspond with those of the " coroners' physicians " or 
" medico-legal experts " of other countries. 
These duties having been entrusted to one of the writers since 
the beginning of the year, or, in ca^e of absence, to the other, 
we think it well now to review the medical evidence given be- 
fore the Coroner's Court during the past six months under the 
new system.f 
We wish first to express our thanks to the members of this 
Society, and to the medical profession in general, for the cor- 
dial support they have given, from first to last, in effecting some 
much needed changes in connection with Coroners' Court in- 
quests. We also wish to thank the members of the Provincial 
Government for the great interest they have taken in the matter 
and the uniform courtesy with which all suggestions concern- 
ing it have been received. 
* Read before the Montreal Medieo-Chirurgical Society, June 23, 1893. 
t As the present paper is chiefly of a general nature it seemed preferable to make 
our communication a joint one, although most of the evidence has hitherto been 
given by one of us (Dr. Johnston). 4 
A beginning has already been made in the direction of 
placing matters concerning medical testomony at inquests on a 
different footing, but owing to some technical difficulties in 
arranging the duties of this new medico-legal office, we have 
only been consulted in a relatively small proportion of the total 
inquests. For this reason a communication limited to our own 
personal observations would not be fairly representative of the 
evidence in the Coroner's Court, so we have, in addition, supple- 
mented our own observations by studying the testimony given 
by medical witnesses in cases where we were not consulted. 
All internal post-mortem examinations ordered by the coroner 
or jury were made by the expert, but as autopsies are only 
called for in a small number of cases, many of the inspec- 
tions of the body, which constitute the majority of the examina- 
tions, were made by other medical men. A radical change has 
not yet been found feasible under the present law, though I may 
state that the present coroner is strongly of opinion that autop- 
sies should be performed in every case where it is necessary to 
hold an inquest. Our information as to medical testimony given 
at inquests where we were not present has been obtained from 
the records of inquests deposited at the Crown and Peace 
Office.* These documents are at all times accessible to any one 
who may wish to see them, and therefore the information 
obtained from them is not of a privileged or secret nature. 
During the six months ending June 30th, 1893, 202 in- 
quests have been held in the Montreal district, out of which 
we have been called to give testimony in 70. During the same 
period 26 autopsies have been ordered, all of which have been 
entrusted to us.f In the remaining inquests, 130 in number, 
the examinations were made by 68 different medical men. 
Except in specially important cases the expert does not examine 
the bodies of those who have been seen during life by other 
medical men. 
It seemed expedient in the present paper to treat the medi- 
* We have to thank Mr. C. Doucet, Clerk of the Crown and Peace Office, for kindly 
aiding us in consulting the records. 
t We take this opportunity of thanking Coroner McMahon for the uniform courtesy 
and consideration which he has shown us in. our capacity of experts, which has 
made our work under him specially agreeable. 5 
cal evidence in a general statistical way only, reserving for 
future and more scientific papers the details of the cases. 
Comparing the work of the Coroner's Court with that of two 
years ago, in 1890 and 1891, we find that then about 240 in- 
quests were annually held in the district of Montreal, and in 
these 12 autopsies were made, so that at present the number of 
inquests is nearly twice as great, and that of autopsies is about 
four times as great as under the old system. 
Taking the population of the district of Montreal as 300,000 
(which is well below the mark), we find that 0.8 inquests were 
then held per year for every 1,000 inhabitants. In Phila- 
delphia 2 per 1,000 are held annually, and in Liverpool 1.7 
public inquests per 1,000, and as many more coroner's private 
inquiries, so that the number of inquests in Montreal is rela- 
tively small as compared with other large cities, the frequency 
for the past half year being at the rate of 1.32 per annum. 
Here, as elsewhere, of all the cases brought to the notice of 
the coroner, only a few finally prove to be medico legal. In 
Liverpool, of 900 inquests held in 1892, only 4 verdicts of mur- 
der and 8 of manslaughter were found, or in other words, less 
than 1.3 per ceut. of the suspicious deaths were found to be due 
to criminal violence or negligence.* In South-west London, out 
of 20,000 inquests during 20 years, there were 8 verdicts of 
murder, 14 of manslaughter, and 59 of infanticide, or 0.4 per 
cent, of criminality.f 
That so much material must be sifted in order to detect 
criminal cases affords an explanation of the fact that we have 
no startling or sensational tragedies to report to you to-night. 
Possibly if more autopsies had been held more crime would have 
been detected, and certainly in two cases the circumstances 
seemed sufficiently suspicious to warrant us, as medical men, in 
suspecting foul play, although as the juries did not think it 
necessary to order autopsies in either of them no positive state- 
ment can be made on this point. 
In the Province of Quebec, as we know, except in exceptional 
cases, it is the practice only to hold autopsies with the consent 
* F. ~W. Lowndes' evidence before committee on death certification, 1893.-British 
Med. Journal, May 6, 1893, p. 962. t Braxton Hicks.- Ibid. 6 
of a majority of the jury. Why a juryman should be supposed to 
know better than the coroner or the medical witness where an 
autopsy is needed is a matter which we cannot pretend to explain, 
but, such being the law, there is at present apparently no remedy 
but patience. 
In Montreal to hold 240 inquests annually meant that 2,880 
jurymen must be empanelled each year to consider the evidence. 
Were the coroner permitted to order an autopsy when necessary 
to establish the cause of death, not only would the entire medi- 
cal evidence be ready for the jury at its first session, but as in 
three-fourths of the suspicious deaths natural causes of death 
could be demonstrated, three-fourths of the inquests would be 
prevented, in other words, 2,160 of the citizens of Montreal 
would annually escape the annoyance of having to sit on juries 
in order to bring in verdicts of death from natural causes, and 
the attention of the coroner and his juries would be concentrated 
on the few really criminal cases. Unfortunately we learn from 
the very highest authority that the holding of autopsies in order 
to prevent inquests is illegal and contrary to the spirit of the 
British criminal law. This is a matter to be regretted, as it 
causes much loss of time and unnecessary expense. 
The British Coroners' Act of 1887, however, empowers the 
coroner to order an autopsy to be performed before the jury is 
summoned ; were this the case here much of the jurors' valu- 
able time would be saved in the minor cases. 
Education of Jurymen.-Out of 1,200 jurymen empanelled 
fora series of 100 consecutive inquests 879 signed their names 
and 321 made their marks. The percentage that signed is 
73.2, and I am informed by Mr. Biron, Coroner's Clerk, that a 
number more were able to write but refrained from doing so; 
some from modesty, others for fear of soiling the paper. We 
may assume that about 80 per cent, of the jurymen were able 
to write, but from . the appearance of the signatures I should 
judge that less than 50 per cent, were persons who had written 
sufficiently often to give any character to the handwriting. 
Some of the most sensible verdicts were rendered by jurors, 
none of whom could write, and some of the most absurd ones 
bore the autographs of all twelve jurors. 7 
Inquests in past Six Months.-In the 202 inquests held from 
January to June, 1893, the following verdicts were returned. 
We have placed in separate columns the cases in which we were 
consulted as experts, and also those in which autopsies were made. 
In 88 cases out of 202 (that is to say, 43 per cent.), the in- 
vestigations were what is known as ex-parte, or held by the 
coroner without summoning a jury. In these cases the sus- 
picions of crime were either very slight or shown to be ground- 
less upon preliminary inquiry. 
The regular fees were not paid to medical witnesses in these 
cases, except in three instances where the medical expert was 
consulted ; in the remainder the testimony was informal and not 
taken under oath. The practice of holding these ex-parte in- 
quests appears to have been discontinued, none being recorded 
in the month of June. In other words, public records are not 
kept of the cases in which, upon inquiry, the coroner does not 
find cause for summoning a jury. 
Table showing relative frequency of inquests before coroners, 
of coroner's inquiries without juries, and of autopsies, for the 
half-year from January to June, 1893. The percentage of 
inquests in which autopsies were ordered is also given for each 
month. This has increased from 7.3 per cent, in the first 
quarter to 14.6 per cent- in the second. 
Months, 1893. 
Inquests 
before 
J ury. 
Inquiries 
without 
Jury, 
Total num- 
ber of deaths 
investigated 
by coroner. 
Autopsies. 
January. •• 
9 
14 
23 
3 
(13 percent.) 
February 
11 
24 
35 
2 
(6 per cent.) 
March 
14 
21 
35 
1 
(3 percent.) 
April 
13 
15 
28 
6 
(21 per cent.) 
May* 
22* 
14 
36 
4 
(11 per cent.) 
June 
44 
ot 
44 
10 
(22 per cent.) 
Total 
113 
(57 per cent.) 
88 
(43 per cent.) 
:01 
26 
(12.8 per ct.) 
* One inquest in a case of arson is omitted, as having no bearing upon medical 
evidence. 
t Since the 1st of June no public record is made of the facts elicited by coroner's 
inquiry in the cases where it is not necessary to summon a jury. 8 
Table showing the verdicts of the Coroner's Court for the 
District of Montreal from January to June, 1893, including the 
conclusions arrived at in ex-parte inquests held without jury in 
minor cases; these are also placed in a separate column:- 
Verdicts. 
<D £ 
M © 
Expert 
called. 
Expert 
not called. 
Total. 
Autopsies. 
I.-Homicidal Deaths. 
Manslaughter 
1 
1 
2 
1 
Jury undecided-Manslaughter or Justifi- 
able Homicide 
Infanticide 
1 
1 
1 
1 
1 
1 
Total 
0 
3 
1 
4 
3 
II.-Suicidal Deaths- 
By Paris Green 
2 
3 
5 
2 
Rough on Rats 
1 
1 
1 
Sulphate of Copper. 
1 
1 
1 
Cutting Throat 
2 
2 
Hanging 
1 
1 
Drowning 
1 
1 
1 
Firearm ... 
1 
1 
0 
Total 
0 
7 
5 
12 
5 
III.-Accidental Deaths. 
Fall into Hold of Ship 
1 
1 
Railway Accident 
7 
3 
10 
1 
StreetCar " 
1 
3 
4 
Elevator " 
3 
3 
Carriage " 
1 
2 
3 
1 
Runaway Horse Accident 
Tobogganing " 
2 
1 
2 
1 
Machinery " 
1 
1 
Firemen on Duty 
Others Suffocated by Smoke 
1 
2 
1 
3 
1 
Fall of Building 
2 
2 
Fall ot Derrick 
2 
2 
Fall down Stairs 
i 
2 
2 
Explosion of Gas 
1 
I 
Blasting Accident 
1 
1 - 
Explosion of Water Pipe 
Burning 
i 
4 
'4 
1 
5 
1 
9 
Scalding 
Inhalation of Gas 
1 
1 
3 
1 
4 
Choked by Food 
Haemorrhage Umbilical Cord 
2 
1 
1 
2 
3 
1 
1 
Over-Laying (Suffocation of Infant in Bed) 
1 
1 
Accidental Drowning 
Administration of Chloroform 
1 
7 
1 
4 
11 
1 
1 
1 
Sudden Death from Lead Colic 
i 
1 
Poisoning by Morphia 
Soothing Syrup 
i 
i 
1 
1 
1 
Chlorodyne (Anticholerique) 
i 
i 
1 
Insolation (Sunstroke) 
• i 
1 
Exposure 
1 
1 
Paralysis from Exposure & Intemperance. 
1 
1 
Total 
12 
39 
37 
76 
5 9 
6 • 
[led. 
sies. 
Verdicts. 
S 3 
7^ 
per: 
lied. 
c5 
o o 
ci 
o 
WZ 
Ex 
ca 
W a 
O 
H 
IV.-Deaths from Natural Causes. 
1. Nervous System:- 
Apoplexy ■ • 
3 
3 
3 
Cerebral Hmmorrhage 
2 
2 
2 
Abscess of Brain 
1 
1 
Congestion of Brain ■ ■ ■ 
1 
i 
1 
Meningitis 
i 
1 
Paralysis 
1 
2 
2 
2. Circulatory System : - 
Heart Disease 
1 
18 
19 
Fatty Degeneration of Heart 
1 
1 
1 
Aneurism 
1 
1 
1 
Syncope of Heart ........... 
1 
1 
1 
Heart Disease aggravated by Intemper'nce 
1 
1 
Syncope of Heart caused by Intemperance 
1 
1 
Cardiac Asthma . 
1 
1 
3. Respiratory System:- 
Asphyxia 
1 
1 
1 
Pneumonia 
3 
4 
3 
7 
o 
Congestion of Lungs. . .; 
1 
2 
Pneumonia or Heart Disease 
1 
1 
1 . 
Inflammation of Lungs 
1 
1 
1 
Pulmonary Embolism 
1 
1 
Haemoptysis, Phthisis ... 
1 
1 
1 
Consumption, Phthisis 
8 
9 
1 
9 
Capillary Bronchitis ... 
1 
Pulmonary Apoplexy caused by Emotion. 
1 
1 
4. Digestive System :- 
Inflammation of Bowels 
1 
1 
1 
Cholera. Morbus .. 
1 
1 
1 
Diarrhoea 
1 
1 
Peritonitis 
2 
2 
2 
Cancer of Liver 
1 
1 
1 
Hepatic Colic 
1 
1 
1 
Jaundice 
1 
1 
1 
5. Urinary System:- 
Urethral Fever . 
2 
o 
2 
6. Generative System:- 
Puerperal Fever 
1 
1 
1 
Metroperitonitis • 
1 
1 
1 
7. Other Diseases :- 
Purpura 
1 
1 
1 
Dropsy 
1 
1 
1 
Infantile Debility 
i 
2 
Senile " .... 
2 
3 
3 
Stillborn ..... 
3 
3 
3 
Sudden Death from Lead Colic, 
i 
1 
Tumour •. 
i 
i 
1 
Incurable Disea.se 
i 
1 
Intemperance 
1 
1 
Total .... 
59 
15 
70 
85 
11 10 
Verdicts. 
[ Ex-parte. 
1 No Jury. 
Expert 
called. 
Expert 
not called 
Total. 
Autopsies. 
V.-Open Verdicts. 
Sudden Death-No cause assigned 
3 
3 
3 
Unknown Causes 
8 
8 
8 
Natural Causes 
5 
6 
6 
Unknown Natural Causes .... 
2 
1 
Canadian Cholera or Poisoning 
1 
1 
i 
Found Drowned 
3 
3 
i 
Total 
16 
6 
18 
24 
2 
Summary. 
Homicides 
0 
3 
1 
4 
.3 
Suicides 
0 
7 
5 
12 
5 
Accidents 
12 
39 
.37 
76 
5 
Natural Death 
59 
15 
70 
85 
11 
Open Verdicts 
16 
6 
18 
24 
2 
Total 
88 
70 
131 
201 
■ 26 
Inquests without Medical Evidence -In 22 of the cases, or 
nearly 11 per cent., no medical testimony at all is recorded, the 
verdicts being as follows :- 
Accidents. 
Natural Causes. 
Open Verdicts. 
■ - 
HurnpH . 
1 
Consumption 
2 
Sudden Death 
2 
Kail way Aeeident 
1 
Pneumonia, 
Natural Causes 
1 
Ae.p.idrdtai 1 v Drowned 
2 
Heart Disease 
2 
Unknown Causes 
5 
Tn halation of Gas 
1 
Pneumonia, or Heart 
Unknown Natural 
Disease 
1 
Causes 
1 
Debility 
1 
5 
8 
9 
Total 
22 
The advisability of saving physician's fees in these cases, if any 
grounds existed for making an enquiry at all, appears question- 
able ; certainly, in those cases where death was not due to acci- 
dents attested to by reliable eye-witnesses, it hardly seems pru- 
dent to act entirely without medical testimony. The fact that 
in 53 per cent, of these cases open verdicts were the result, 
speaks for itself. 
Upon looking at the ex-parte inquiries it will be seen that out 
of a total of 88, 59 (i.e , 67 per cent.) were in connection 
with cases where death appe ired to be due to natural causes. 
In other words, two-thirds of these cases were essentially of a 11 
medical nature. If we exclude the 12 accidents where, of 
course, the nature of the violence was obvious and only the 
question of responsibility remained to be decided, we find that 
out of the 66 remaining cases 89 per cent, were assumed to be 
due to particular diseases. As the remaining open verdicts in 
16 cases were probably also of a medical nature, we find only 
12 cases out of the whole 88, or less that one-seventh; were 
what might be called non-medical. No better proof of the 
necessity of expert medical work in minor cases in the Coroner's 
Court could be afforded than is shown by this analysis of the 
material. 
Taking the entire number of cases dealt with, 202, and de- 
ducting 24 open verdicts, 1 case of arson and 76 accidents 
where the nature of the violence which had caused death was 
obvious in almost every case, we have 100 cases left. In these, 
85 verdicts of death from natural causes were returned, making 
it evident that of 100 deaths under circumstances arousing the 
coroner's suspicions, 85 per cent, were essentially medical in 
nature, and therefore required skilled medical investigation to 
decide their real nature, in addition to the medico-legal study 
of the 15 really medico-legal cases remaining. 
In several of the suicides, autopsies were ordered to establish 
whether the patient was of unsound mind, and in one case 
fairly positive proof of this was obtained, large symmetrical 
cystic spots of softening being found in the brain. 
In the cases of suspected infanticide autopsies were invariably 
performed, the coroner rightly deciding that the proof of the 
child having breathed was indispensibk. Under the old regime 
of a few years ago autopsies were never held in these cases, and 
frequently even the inquest was omitted. 
In one case of death after a private surgical- operation pro- 
fessional questions of a sufficiently delicate nature threatened to 
arise, but the friends having come to the conclusion that the 
surgeon had acted for the best withdrew their demand for an 
investigation, much to our relief. 
Pneumonia was found to be a frequent cause of death under 
suspicious circumstances. In one case where a verdict of death 12 
from alcoholism had been rendered, and in consequence burial 
in consecrated ground was denied, a private autopsy showed 
that pneumonia was the cause and the restriction was withdrawn. 
We do not think it well that private autopsies should be held in 
such cases, as it would appear to be only just that the Govern- 
ment should investigate the matter fully if the friends are not 
satisfied with the verdict, even if there is no crime. This would 
be decidedly more dignified than having the finding of the jury 
repeatedly shown to be wrong by the results of private autop- 
sies afterwards made. In France an appeal of this kind always 
receives careful official consideration. 
In one of our cases classed as debility and one of pneumonia, 
both in children, very clear evidence was forthcoming of neglect 
on the part of the parents. A number of other instances of 
this have come under the notice of the coroner. In these cases 
it is impossible to proceed in the absence of the evidence given 
by autopsies, as if the child really suffers from an incurable 
organic disease, and the life could not have been saved by 
ordinarymedical and other care, criminal negligence could hardly 
be proved. 
It may be remarked in this connection that our present law, 
which makes parental neglect amount either to manslaughter or 
nothing, makes it impossible to get incriminating verdicts from 
the juries. In England offences of this kind may be dealt with 
as misdemeanors and a moderate fine or short imprisonment in- 
flicted after a summary trial. Such a change in our criminal 
law would be the means of saving many young lives, and we 
would commend it to the attention of the Society for the Protec- 
tion of Women and Children, or to our Citizens' League. We are 
glad to learn that a society is being formed to deal with this 
matter. 
It will be noticed that no cases of criminal abortion were 
brought to light, although we know that they are frequently 
performed in Montreal. We have been told on reliable authority 
that competition has reduced the charge for this operation in 
certain quarters to ten dollars. Were an autopsy performed in 
all cases of suspicious death it is not unlikely that some deaths 13 
now assigned to natural causes would prove to be cases of this 
character. One of us knows of a case which happened some 
years ago and where a woman died of severe uterine haemor- 
rhage under most suspicious circumstances. In this case heart 
disease was stated to be the cause, upon the strength of an ex- 
ternal examination. 
In none of the cases of poisoning by gas was any proof of 
the presence of carbon monoxide asked for. One of the favourite 
verdicts still continues to be death from exposure. We have 
examined two of these externally and reported the absence of 
external signs of fatal disease and the necessity of an autopsy 
being held, but none was ordered in either case. 
Coming finally to 20 verdicts of " natural causes " and " un- 
known causes " these might equally well have been rendered in 
at least 50 other cases, so far as can be learned from the records. 
We see no objection to the verdict of unknown causes being ren- 
dered, but how, when the cause is unknown, it can be stated to 
be natural, is a matter of which the explanation must be left to 
the juries who have found this verdict. A fine instance of the 
perspicacity of a jury was recently given in a case where every- 
thing pointed to poisoning by arsenic or corrosive sublimate. 
After the inquest was over, a private analysis found evi- 
dences of the presence of arsenic in this case, and the possibility 
of cholera morbus as a cause was definitely excluded at the 
autopsy. The jury found, " that the deceased came to his 
death either by cholera morbus or by poisoning. It is not pos- 
sible, without making a chemical analysis, to determine which 
of these causes is the true one, and in the present case is of no 
consequence." In the words of Ruddigore, " It really doesn't 
matter I " 
In another recent case where an individual had disappeared 
for two days, at the end of that time his dead body being 
found locked up in a cottage, with the furniture strewn about 
and overturned and with marks of violence about his face, the 
verdict returned on the strength of the medical evidence was 
death from a convulsion due to chronic lead poisoning. This was 
one of the cases in which we were not summoned to examine 
the body. 14 
In the case of bodies which have lain some time in water, 
putrefaction sets in with extreme rapidity. We have seen bodies 
freshly removed from water, and in which much could be made 
out by an examination made at once, putrify so rapidly that in 
a couple of hours they had become quite unrecognizable. Our 
only inconclusive autopsies were held upon drowned bodies which 
had thus putrefied. 
The only satisfactory means of preventing this is by having 
a refrigerating chamber .similar to that in use at the Paris 
Morgue, where bodies are promptly placed in a dry, cold atmos- 
phere of about 5V Fahrenheit for 24 hours, and afterwards pre- 
served indefinitely in a cold chamber kept at about 25° to 35°. 
This latter is furnished with a glass front and placed in a passage 
accessible at all times to the public. If necessary the bodies 
may be kept years in this manner, and may not only be identi- 
fied at the end of that time, but if gradually thawed out an 
autopsy may be performed, with results almost as conclusive as 
on the fresh cadaver. In this way there is no nuisance or 
danger to health. 
Comparing the results of the past six months with a period 
of six months in 1890, we find that then in a half-year, out of 123 
inquests, in 16 cases the verdict was simply " found dead," 
and in not one of these was an autopsy made ; out of 7 cases 
of cerebral apoplexy no autopsies were made, and for one ver- 
dict of " cerebral congestion " no medical testimony was taken. 
" Synecopy " of the heart was responsible for 7 deaths, no autop- 
sies being ordered, and pulmonary congestion for 4 cases, of 
which 3 were in the case of unknown persons found dead-no 
autopsies. One case died of a " broken heart," and one of 
" angelis pectoris," 9 were found drowned, 4 accidentally 
drowned, and in 8 cases medical testimony was not called for. 
To a certain extent, " nous avons change tout cela" but 
even during the past six months some medical opinions have 
been given which is sufficiently remarkable. I mention a few 
only. " Sudden death from hepatic colic " in a child three 
days old, and without jaundice, is odd, to say the least. " Con- 
gestion of the brain caused by fatty degeneration of the heart" 15 
is also an original idea, and worthy of a niche in history. Sud- 
den death from " metro-peritonitis " in a patient who seemed 
to be in perfect health up to the moment of her death, is an 
observation which it falls to the lot of very few to make. In 
one case, when the patient complained of pains in the region of 
the stomach for several days before death, and had a consider- 
able haemorrhage on the night of his death, we find the state- 
ment that death " must have been due to heart disease or 
pneumonia." In half of the cases where death is stated to have 
been due to heart disease, the medical men had never seen the 
cases during life. In no heart cases is any attempt made 
to note whether any objective signs of heart failure, e.g., dropsy, 
clubbed nails, etc., were to be seen on the body. In one case, 
" congestion of the lungs " was diagnosed post-mortem from 
external examination by a physician who had never seen the 
man alive, but the secret of the process is not imparted. 
In one case, where a death occurrred in a public institution, 
and the patient had been ill several days without the doctor 
having seen him, the jury are careful to state that " no blame 
is to be attached to the authorities, but, on the contrary, they 
deserve praise for the good care they took of the deceased." 
(" Au contraire, des louages pour leur bon procedes d Vegard 
du defunt."^ This was certainly very considerate of the jury, 
but politeness may be carried too far. 
In the case of a woman who died suddenly, death should 
hardly have been put down to heart disease when nothing 
more definite than " oppression " had been complained of dur- 
ing life, although a doctor called in after death " had no objec- 
tion to believe " that she died of this favourite lethal agent 
of coroners' courts. The only reason seems to be that the 
family were respectable people (jdes braves gensd) Something 
more tangible should be forthcoming as a proof of the cause of 
death when the imposing machinery of a Coroner's Court has 
once been set in motion, even in the case of the most respect- 
able families. The same physician had equally little objection 
to believe the same thing in another case on equally slender 
grounds. 16 
In this matter of determining the cause of death, coroners 
are placed in a very difficult position, because the law does not 
require them to find out the exact cause, but merely to see 
if a crime has been committed. To incur expense which 
does not lead to the detection of crime is considered one of the 
cardinal sins. That neighbours' testimony as to the character 
and habits of the suddenly deceased is of great value in afford- 
ing what in law is called a " presumption " against crime there 
can be no doubt, and from study of the records I can testify to 
the great pains which our own coroner always takes to investi- 
gate this side of the question. In all the records the following 
points are carefully covered by the non-medical testimony :- 
1. Marks of violence absent. 
2. No external signs of poisoning. 
3. Deceased stated to have eaten and drank only those 
things taken without ill effect by others. 
4. Deceased did not, from conversation or behaviour, lead 
the friends to suppose that suicide was contemplated. 
5. Deceased not known to have enemies. 
Now, these points, important as they are, do not prove a 
natural death. The utmost interpretation which could be put 
upon them is " death from unknown causes, without suspicion 
of crime." This is better than attributing the death to unspeci- 
fied " natural causes," and much better than ascribing it to an 
imaginary heart disease which probably does not exist in the 
majority of cases. 
The laity always suspect poison when death is sudden, but 
the medical profession knows that but very few poisons exist 
which can cause people to drop dead. The external evidence 
of poisoning is usually absent, or at least has not been present 
in any of the four cases we have examined. Absence of state- 
ments as to intended suicide would not seem to be of much 
value, judging from the fact that in only one of the 12 cases of 
suicide which have been investigated had any statement been 
made by the victims of their intention. People who talk suicide 
seldom commit suicide. The great disadvantage of all this sort 
of evidence is that it is mostly obtained from those who may be 17 
interested. As Coroner McMahon has often pointed out, peo- 
ple in large cities know very little about the doings of their 
neighbors, the conditions being quite different from those obtain- 
ing in country places. When death from unknown causes 
satisfies the ends of justice, well and good ; but for any 
more explicit cause of death it would be simpler, instead of try- 
ing to exclude the many possible causes which are absent, to 
find out the one real cause. 
We have a great admiration for juries in general, and admire 
the spirit of fairness invariably shown by our Canadian juries in 
particular, when human interests are really at stake. Their 
sympathy for the wronged and unfortunate is worthy of all 
praise, and they stand in no awe of the corporations which 
oppress us, but as an institution for finding out causes of death 
they are not an unqualified success 
When the cause of death is not clear without an autopsy we 
have made it our practice simply to state that fact. This has 
had the result, not of an increased number of autopsies, but in 
an increased number of deaths from unknown causes-presum- 
ably, visitation of God. We live in hopes that these numerous 
" visitations of God " may tend to hasten a millenium when 
autopsies will be more frequent. 
The first and most important duty of the medical witness is 
to ascertain the cause of death, and it is satisfactory to know that 
of the 26 autopsies held the cause, of death could be definitely 
stated in every case except three, two where the bodies had 
remained a long time in the water and become greatly decom- 
posed, and one shown to be due to poison. Even in these un- 
promising cases, however, the important medico-legal points 
could be determined at the autopsy. Presuming that the 
same precision as to the cause of death would have been 
attained in the remaining cases, we may assume that had autop- 
sies been made at all the inquests about 180 deaths out of 201 
would have been satisfactorily explained. 
In 14 accidents, ^where external examinations only were 
allowed, the cause of death could only be made out satisfactorily 
in 6, 2 having broken necks, and 4 having the skulls completely 18 
crushed in. In the remainder we confined our statement to 
the fact that sufficiently severe external injuries existed to be 
compatible with the presence of fatal internal injuries not evident 
from external examination. 
When no accident had taken place the external examination 
gave almost uniformly negative results. In 16 such cases we 
confined ourselves to the statement that it was impossible to state 
the cause of death from the external examination, and that if 
the determination of the cause of death was necessary an autopsy 
would have to be made. In no case did we make any attempt 
to guess at the probable cause. 
In following strictly this rule we were guided by the princi- 
ples laid down by Brouardel, probably the greatest of all living 
medico-legal experts, that the duty of the expert in medico-legal 
cases is to state either that a certain fact is proved, or that it 
is not proved, and to show sufficient facts in support of any con- 
clusion drawn to make the testimony amount to a demonstration. 
Demonstrations, not opinions, are what is wanted. In no case is 
a witness in medico-legal cases justified ingiving his opinion un- 
less he can support it by statements of acts which establish its 
correctness. The great reputation now enjoyed by the French 
school of legal medicine is as much due to their strict adherence 
to this principle as to the brilliancy of their methods and the 
clearness of their logic. 
Unfortunately the necessity for this scientific attitude is 
not yet appreciated by many of those who give evidence be- 
fore coroners. If they do not know the cause of death they feel 
bound to hazard a guess and appear to know all about it. 
Much of the loose medical evidence given before coroners is 
due to the pertinacity with which juries will persist in asking 
whether the cause of death may not probably or possibly be due 
to such and such a thing. If the least admission is made they 
will promptly render a verdict to that effect, for which the medi- 
cal witness becomes virtually responsible, though fully aware 
that there are a dozen other causes, any one of which may be the 
right one. The only resource of the medical witness is to refuse 
to say more than is established by the facts which have come 19 
under his notice. He is under no obligation to say what might 
have been, but only what was the case, if he can. " Of all sad 
words, the saddest are these-' it might have been,' " when they 
form part of medical evidence before coroners ; and to this and 
unfounded medical testimony rather than neglect of juries must 
be held responsible for much that is regrettable in the past six 
months' evidence. 
We have wondered not a little in reading the records of in- 
quests why it is that medical witnesses so seldom make a written 
statement of the facts which they observe, and of the conclusions 
which they have drawn from them. In the past six months, 
apart from our own testimony, this does not appear to have been 
done in a single instance ; and yet it would form the greatest 
safeguard a medical man could have against any future charge 
of giving a wrong opinion, as at any future time by consulting 
the record it could be shown why that particular opinion was 
given. This is the universal practice in other countries, and 
witnesses are obliged by law to state the facts upon which they 
form their opinions. There is no need for any reserve or hesi- 
tation in stating facts. Personally, in following this system we 
have found that time is saved and cross-examination shortened 
if a written report is submitted. We can confidently recom- 
mend this plan to others. 
We constantly find that too little time is given to prepare a 
report, because the jury has to meet at a certain time. In 
France a physician charged with an " expertise " is given as a 
rule a week in which to prepare his report, unless the matter is 
specially urgent, and a clear 24 hours should certainly be 
allowed. 
It should be borne in mind that the medical opinion in an 
ordinary death certificate, where no grounds for suspicion ex- 
isted, is only heeded for general statistical purposes, and there- 
fore approximate accuracy in a large number of cases suffices. 
Where, on the other hand, suspicion of a crime exists, what is 
wanted is, as nearly as possible, absolute accuracy in the one 
particular case. Slight inaccuracies in a mass of general statis- 
tical information tend to correct themselves. Serious inaccuracy 
in a single important criminal matter is quite inexcusable. 20 
Great inconvenience is caused by the absence of an official 
clerk or secretary to take notes of the autopsy, so that the 
physician could always describe appearances while they were 
before his eyes. In other countries this is always attended to 
by a special official. Apart from the physical labour of writing 
out a long report, there is great danger that facts will be for- 
gotten and error creep in if the memory is trusted to. Besides 
this, in the act of description new points are suggested for in- 
vestigation which otherwise may be forgotten till it is too late. 
Another defect is the absence of any system by which written 
instructions as to the nature of the information wanted is fur- 
nished the expert. In France and Germany a definite series 
of questions are asked the expert, and he thus knows what is 
expected of him and can give full information upon the vital 
points of the case. Official regulations are also greatly needed 
as to the technique to be followed in making an autopsy. Were 
there any instructions as to the advisability of some of the 
clothes of the deceased being removed before the autopsy is-con- 
sidered finished, we should not recently have heard of under- 
takers discovering bullet wounds unnoticed by the medical ex- 
perts during their post-mortem. 
Another important matter is that arrangements should be 
made by which the expert shall see the body before it has been 
disturbed. In six months' work we have hardly seen a single 
body in the state and with the conditions and surroundings 
which existed at the time of death. It is almost always trans- 
ported, undressed, placed in a coffin, or otherwise interfered 
with. In some instances embalming had even been done by 
the undertaker. 
The chief complaint against the Coroner's Court in the past 
has been in regard to want of precision respecting the causes of 
death assigned. We have seen that in the past six months a 
material improvement in this respect has taken place, and a 
larger number of the causes of death are supported by some 
tangible evidence. This improvement, however, has been 
limited to those cases where autopsies have been performed, 
and until this is done in every case where inquests are held it 21 
is not likely that the verdicts of coroners' juries will be taken 
as representing the truth, the whole truth and nothing but the 
truth, about the deaths which they investigate. Apart from 
accidents attested to by eye-witnesses, about 90 per cent, of all 
the cases coming before the coroner are cases of natural death, 
and without the control afforded by the results of post-mortems 
and the counsel of a medical expert, it is not reasonable to 
expect a coroner having a legal training only to estimate the 
amount of credence to be attached to all the diverse medical 
evidence given in these cases. Taylor wrote, over thirty years 
ago: "As a general rule, it may be stated that inquests in 
which there is no medical examination of the body are a vain 
mockery, and the sooner the public becomes imbued with that 
idea the better it will be for society." Whether this still holds 
good of Montreal inquests may be judged from the results we 
have given of the past six months' work. 
It is our experience that where an external or partial 
examination only is made the results are nearly or quite value- 
less. Hence, in cases where no autopsy is performed the 
investigation cannot be regarded as a serious one from a medi- 
cal standpoint. 
Although the number of autopsies held shows an increase 
as compared with former years, yet, even now, in 200 inquests 
only 26 autopsies were held, or, in other words, only 12 per 
cent, of the cases of suspicious deaths received serious medical 
investigation, although nominally over 200 examinations of the 
body were made (and paid for.) 
It may be stated that in 76 cases of acccident, forming 38 
per cent, of the total, the death was obviously due to an acci- 
dent attested to by eye-witnesses, and that a medical examina- 
tion was superfluous. If it was superfluous, why was it made 
at all ? If it was necessary, why was it not ordered to be 
made thoroughly ? Why is it that autopsies are often hurriedly 
done, " while you wait," because the jury are in a hurry ? 
It appears that further reform in this matter is urgently 
necessary, and we may conclude by mentioning briefly the 
directions in which it should be made :- 22 
1. Autopsies should be performed in all cases of suspicious 
or sudden death where the cause of death is doubtful. 
2. The coroner should be allowed to decide whether an 
autopsy is necessary, and to order it to be performed, if advis- 
able, before the jury meet. (English coroners, under Vic. 50 
and 51,' cap. 71, are allowed full discretion as to the ordering 
of autopsies and the time when they shall be held.) 
3. In medical testimony, the observed facts upon which 
opinions are based should always be stated, preferably in writing. 
The improvement which has been effected already is a hope- 
ful indication for the future, and we hope in the report of the 
next six months' work to be able to show a decided advance over 
that of the past half year, which may be regarded in the light 
of an experiment.