—■■■■■ 1 I I \ 
THE LAW JOF/ C0R0NERS7^“ 
BY THEODORE H. TYNiWlE, COUNSELOR AT LAW. 
Mr. Chairman and Gentlemen, — The subject of coroners and 
coroners’ law which we are about to discuss this evening has lately- 
excited a good deal of attention both in England and in this country. 
The immediate cause of this attention in both countries has been the 
same. In both the proceedings in recent cases have been of a nature 
to lead many persons to doubt the propriety of the existing laws and of 
the procedure under them, and to inquire into the advisability of a 
change in the constitution and the conduct of the coroner’s court. 
It is my pleasing duty to place before you briefly the laws on the 
subject now in force in this Commonwealth, to notice the proceedings 
and practices that have grown up under them, and thus to open the 
way for your discussion of the remedies, if there be any, that may seem 
desirable. 
The office of coroner is one of very remote origin. In England it 
could formerly be held only by “ lawful and discreet knights.” His 
functions were originally those of a conservator of the peace, and generally 
a ministerial deputy of the crown. He took the place of the shire-reeve 
(our present sheriff), or governor of the Count, during his absence or 
incapacity. Part of his duty was the collection of the revenues; to 
“ inquire of wrecks and of royal fishes, such as sturgeon, whales, and 
the like; he took charge of forfeits to the crown of such moving 
articles — cattle, horses, or wagons — as directly contributed to the death 
of any person ; and finally, he came to represent the crown in criminal 
cases where a dead body was found and violence or crime was suspected. 
With an exception hereafter to be noted, the latter duty is the only 
one with which, in this country, he is now charged, and which at pres- 
ent concerns us. The constitution of his court, the conduct of proceed- 
ings before and the manner of his appointment are the same now in 
England as tjhey were in the time of Elizabeth. In this country the 
1 Read beforeqhe Department of Health of the American Social Science Association, and 
reprinted from the Boston Medical and Surgical Journal, March 1, 1877. 
The writer desires to acknowledge his indebtedness in the preparation of this paper to 
the admirable address of Mr. Herschell, Q. C., M. P., delivered before the British Social 
Science Association, at Liverpool, in October, 1876. 2 
The Law of Coroners. 
only change has been in the manner of appointment. From time im- 
memorial the coroner has been assisted in his investigation into the 
cause and manner of a violent death by a jury. Differing from time 
to time in the number composing it, it was always summoned from the 
immediate neighborhood of the place where the dead bodv was found, 
and still must be “of the county.” Formerly the jurors were sum- 
moned as witnesses or accusers rather than as judges. Until the fifteenth 
century the jury themselves were the witnesses and the only witnesses, 
they being selected with reference to their knowledge of the facts, and 
no other witnesses being; examined and no evidence whatever being- 
offered to them. Though no longer selected for the purpose of obtaining 
from them the facts in the case, nor at all likely in towns or cities to 
have any previous knowledge of the facts, they are to this day sworn 
to return a true inquest according to their knowledge and such evi- 
dence as shall be laid before them. With this brief outline of the cor- 
oner's historical position, let us now pass to the actual position he occu- 
pies under our laws. 
Coroners are appointed by the governor and council. They give 
bond in the sum of five hundred dollars, and are sworn. If on view of 
a dead body found the coroner deems it necessary to hold an inquest, 
he does so upon being authorized in writing by the attorney-gen- 
eral, district attorney, mayor, chief of police, or the selectmen of the 
town in which the body is found. In cases of railroad accident no 
such authority is necessary. The coroner issues a warrant to some 
constable, who summons six men of the county as a jury. If six do not 
appear, the number is completed from the by-standers. No person is 
allowed to serve on the jury oftener than once in twelve months. The 
inquest may be secret with the consent of a majority of the jury, and 
the witnesses kept separate. The testimony of the witnesses is required 
to be written down by the coroner or by some person at his direction, 
and signed by the witnesses. The verdict, the written evidence, and 
all recognizances and examinations taken by the coroner must be re- 
turned to the superior court within thirty days. If the jury find that 
a murder, manslaughter, or assault has been committed on the deceased, 
the coroner may bind over the witnesses or commit them, and if the 
person charged with the offense is not in custody the coroner may issue 
a warrant for his arrest. 
Coroners hold their commissions for seven years. Their fees are, 
for a view, four dollars; for an inquest, five dollars for the first day and 
four dollars for each subsequent day. Witnesses get the fees allowed 
in a justice’s court. The person writing the testimony gets one dollar 
and a half per day. The constable for summoning the jury and attend- 
ing the inquest gets two dollars per day. A surgeon or chemist may 
be employed by the coroner to aid in the investigation. He receives The Law of Coroners. 
3 
what the coroner certifies to be reasonable. The practice is to allow 
thirty dollars for an autopsy and fifty dollars for a chemical analysis. 
When no coroner lives in the place any justice of the peace may per- 
form his duties. Property found on or near the dead person is taken 
charge of by the coroner, who must deliver it to those entitled to its 
possession. 
The district attorney must be notified of an inquest when the coroner 
thinks a murder or manslaughter has been committed. He may attend 
and examine and bind over witnesses. 
In every county two special coroners may be appointed, who alone 
can take the sheriff"s place. When the sheriff is a party to proceedings, 
or the office is vacant, these coroners serve process and perform his duties 
until a new one is appointed. These special coroners give bond “ to 
the satisfaction of the superior court.” Coroners are removable by an 
address of both houses of the legislature to the governor. In case of 
breaking their bond to the injury of any person, if the execution is not 
paid in thirty days a proceeding for removal may be begun before the 
governor and council. 
In practice a person desiring an appointment as coroner presents a 
petition more or less numerously signed, with one or more names of 
men of presumed respectability upon it; this is handed either to the 
councilor for the district in which the applicant resides, or to the governor 
in person. In the latter case the petition is referred to the councilor 
for the district for his investigation and report. Upon his favorable 
report the applicant is appointed. Sometimes a verbal application alone 
is made, and personal representations of friends are quite frequent; in- 
deed, they are the rule. 
The appointment of certain officers is supposed to be preferable to 
their election, by reason of the independence and the better class of 
material thus to be secured, since election is a matter of popular favor, 
of chance, and party ascendancy, and is no guarantee of proper qualifi- 
cation for office, while appointment permits selection for quality and fit- 
ness. Practically, it is impossible that the appointing power should be 
personally acquainted with individuals to be appointed when their num- 
ber is large; thus the benefits arising from this system within certain 
limits are liable to fail beyond these. In such cases personal judgment 
of quality is necessarily supplanted by reliance on the representation of 
others, and thus the element of risk enters. No amount of care can 
then obviate all mistakes, and if mistakes occur it is not the fault of 
the appointing power, but of the law requiring the exercise of discretion 
beyond its natural bounds. The first thing that attracts attention in 
the law is that it fixes no limit to the number of coroners that may be 
appointed, and in practice this attention is justified by the facts. 
The following figures will illustrate the outcome of this feature of 4 
The Law of Coroners. 
the law : London, with its enormous population, has four coroners ; 
New York, with a population three times that of Boston, has four, with 
one medical deputy each ; Brooklyn, with a population one third to one 
half greater, has tivo ; Philadelphia, New Orleans, and Chicago, two 
each ; San Francisco, Baltimore, Washington, and Cincinnati but one 
each, — a total of twenty-four for all these large cities taken together. 
Suffolk County, consisting chiefly of Boston, has forty-seven coroners, 
of which the city of Boston alone has, or had a week ago to-day when 
I copied the record, forty-three, almost twice as many as all the above- 
named cities combined! 
What results can you reasonably expect from such an unlimited, 
indiscriminate distribution of office ? Will it not naturally tend to 
deteriorate the quality, and thus lower the tone of the whole body ? 
We might fairly assume that in time no person fit for the office will 
accept one which is given away to any and every comer. Without 
here calling in question the personal probity or fitness of any person 
now holding the office, and without denying that it is still held by 
many worthy and competent gentlemen, it is not venturing too much, 
perhaps, to say in general terms that the standard of quality lias been 
lowered. This is recognized and felt most severely by those in the 
office who are qualified and fit for it, but are conscious that the prac- 
tices of others have brought the office to the verge of disrepute. 
Of the forty-three coroners in Boston, thirty are regular physicians 
and members of the Massachusetts Medical Society, two are registered 
as members of the Massachusetts “ Eclectic Medical Society,” seven 
are what is known as “ other physicians,” while four are non-profes- 
sional gentlemen. Of these last, one is an auctioneer, another an insur- 
ance agent and broker, a third vends patent medicines, while the fourth 
figures simply as “ notary public and coroner.” 
Now, how important is it to have men of superior character to fill the 
office ? What does its possession entrust them with ? 
You have in the coroner an officer armed practically with the utmost 
powers of the law. He decides in the first place, upon bis discretion, 
whether an inquest be necessary or not; it is obvious how large are the op- 
portunities for corruption in this direction : that for a man whose cupidity 
or possibly culpability and fear are stronger than his honor and integrity, 
it would not be difficult to thwart justice and close the door to all judi- 
cial investigation of a crime by corruptly declaring an inquest unneces- 
sary, and even aiding in the removal of suspicion and the concealment 
of the evidences and traces hy authorizing a speedy burial. But if he 
may thus on the one hand shield the guilty and endanger the public 
safety, on the other the opportunities for a man prompted by malice or 
vindictiveness or the desire of cheap notoriety are enough, truly, to 
make us tremble. With full judicial powers of examination and com- The Law of Coroners. 
5 
mitment, with his chosen constable selecting his own jury, with supreme 
control of the investigation, which with the consent of part of -his jury 
he may make secret, with the selection of his medical witness, and the 
power to summon and hear or omit and exclude whomsoever he will, 
uncontrolled by superior authority and responsible practically to no one 
for his action, he may bring ruin upon a life, or forever cloud and em- 
bitter it, throwing suspicion on the character of the living and blacken- 
ing the memory of the dead ; he may oppress and harass a stricken 
household without cause and without justification, — in one word, he 
may make an inquest in the worst sense of the term an Inquisition. 
Will you entrust such powers to a man of any but the highest 
character, — whose integrity is above reproach and above suspicion ? 
This you cannot be sure of by unlimited appointment; and such an of- 
fice as I have described should surely not be given to one whose past 
life and character are such as to fail to inspire confidence in his disposi- 
tion to resist dishonoring proposals or the belief that he is free from 
fouler motives. 
I propose, therefore, in the first place, a reduction in the number of 
coroners. 
As a matter of fact the inquests in Boston, notwithstanding the large 
number of coroners, are mostly held by some six of them. The con- 
stant practice of other cities proves that a smaller number will suffice 
for all wants. 
By such reduction, besides preventing a great danger and present 
evil, you gain corresponding positive good : 1st. Each individual of a 
smaller number of appointees may be personally known by the appoint- 
ing power, as are all the judges appointed in this State. 2d. You in- 
crease the dignity of the office and awaken that jealous public attention 
which always watches the appointee to a trust of dignity and importance 
and scans his qualifications. Whether there should be one chief with 
deputies, or several with coordinate powers, is an open question. It 
seems to me there is more likelihood of even excellence by making 
several co-equal appointments. 
A few words as to the practice in regard to the jury. The constable 
being chosen by the coroner is not likely, as human nature goes, to ex- 
ert himself unnecessarily, or to conflict with his views or desires in 
selecting the jurors whom it is his duty to summon. Except in cases 
where public attention has been pointedly aroused, the class of men 
chosen to act as jurors is proverbially inferior in moral standing and in- 
telligence. The books teem with stories of their ludicrous and absurd 
verdicts. The hangers-on of the constable’s office are generally in 
requisition. Previous to 1860, indeed, the business of professional jury- 
man had grown to such extensive proportions that it was found neces- 
sary to enact a provision that no man should serve oftener than once in 6 
The Law of Coroners. 
twelve months. But even now a deficiency in the number of jurymen 
may be made up from “ the by-standers.” 
The jury are to give a verdict. In practice I do not believe the jury 
do this once in ten times. The coroner suggests and even has written 
out beforehand, in appropriate language, the verdict that his judgment 
approves. This is submitted to the jury, and in most cases accepted by 
them without dissent. I once had the honor of officiating as foreman of 
such a jury. After the evidence had been heard, to the utter surprise 
of one of us, the coroner, who was standing at that moment in another 
part of the room, said : “ This is all the evidence, gentlemen ; the clerk 
has drawn up a verdict in accordance with the facts, which he will now 
read to you.” And really that clerk had found our verdict before we 
had. But then he was an experienced clerk. 
The usefulness of the jury, when judged by its work, is not apparent. 
Nurtured in tradition and deriving most of their store from its sources, 
lawyers are naturally attached to what is old ; but for one I do not 
favor circuitous modes of action where direct ones answer the same 
end. Now' here is an opportunity too good to be lost for straightening 
a very roundabout road. 
The coroner notifies a constable, the constable summons a jury, the 
jury are sworn, the body is viewed, the testimony is heard, the verdict 
is returned, —and what do you do with it? Absolutely nothing ! We 
get together a number of men, we inform them of certain facts and ask 
them to draw a conclusion from those facts, and for what purpose ? 
Their verdict is not conclusive, it is not evidence, and is not even 
used at the subsequent trial; the statements there made by the -wit- 
nesses are not evidence, the prisoner is not bound over upon it, nor 
until after a rehearing of the whole matter in the criminal court. Well, 
then, to what end is all this needless machinery and expense ? To fur- 
nish an item for the evening press ? Is there any service to the State ? 
Is there any additional safety to the individual ? I apprehend not; and 
we shall see farther on that there is a material and grave danger. The 
safeguard of the jury is interposed between the interests of the two, 
upon the trial ; the accused has all the protection of that mighty bul- 
wark of liberty there, and the coroner’s jury does not add to it one par- 
ticle. Whatever the verdict, the courts proceed without and inde- 
pendently of it in this country. 
In England, the coroner, when a verdict accuses any one, still does 
bind him over to appear at the next assizes; but there is instituted a 
parallel proceeding by indictment in the regular courts, upon which 
alone he is tried. And if the courts, finding no cause to indict, dis- 
charge the prisoner, he is nevertheless bound to appear at the assizes to 
which the coroner’s action referred him, and be there discharged. This 
extent of solemn and meaningless mockery does not obtain with us. The Law of Coroners 
7 
We simply do nothing with the coroner’s verdict, without the pretense 
of doing something. 
Here the coroner practically never binds over a suspected person, he 
being almost invariably in custody before the coroner knows anything 
about the matter. So that the coroner and his court, judicially consid- 
ered, are a meaningless, but, as we have seen, by no means harmless 
anomaly. They serve no purpose, no results flow from their work, and 
they cause danger, evil, and expense. 
Upon these grounds, therefore, I advocate the abolition of this useless 
body. 
Having before determined the question of the character necessary for 
a coroner, let us turn our attention to his qualifications. One impor- 
tant fact must be kept steadily in view : the sole purpose of the coro- 
ner’s inquest is the detection of crime. With a death unaccompanied 
by circumstances of suspicion the coroner has no concern. When such 
suspicion exists his functions are twofold. One is to determine with cer- 
tainty whether the death has resulted from natural causes or from vio- 
lence. By the term violence I here mean not only physical force, but 
poison and all means of death not in the ordinary course of nature. 
The other is to determine, if it be found to be a case of violence, how 
that violence was caused, and whether it constitutes a crime or not. 
One is a question of medical investigation, the other a question of legal 
determination. One is answered by a physical examination, the other 
by an inquiry into external facts, and the application of the laws to 
those facts. One is essentially the function of a physician, the other 
essentially the function of a lawyer. 
I am not going to offend your ears by saying that the office is a judi- 
cial and not a medical one. It is composite, being neither judicial 
nor medical, because it is both, — a nondescript. Nor am I going to 
assert that it should be held by a lawyer. I only ask you to accom- 
pany me into an examination of the functions of the office as just indi- 
cated ; these once clearly understood, the much-disputed question will 
decide itself. Let us only clearly understand the duties involved in its 
performance, and the respective relations of medicine and law to them, 
and all dispute is at an end. 
What takes place when an inquest is held ? In the first place the 
coroner decides whether it be necessary to hold one. This is clearly a 
matter of medical science, as the appearance and inspection of the body 
must chiefly determine it. Does lie decide one necessary, the next 
thing is to convoke a jury to examine into the facts relating to the death. 
This is a matter of hearing testimony from witnesses ; and the very 
statement of this function shows it to be clearly legal. One part of the 
facts to be heard by the jury is the condition and appearances of the 
body, and the scientific deduction from these; this again is evidently 8 
The Law of Coroners. 
only a medical field ; one part of the jury’s duty is to make up a verdict 
upon the facts ascertained by evidence, and the law applicable to those 
facts as laid down by the coroner ; this again is a province clearly legal. 
Whether a given death result from natural causes or not, so far as the 
body indicates, the physician’s examination is competent, and alone 
competent to decide ; whether, the fact of violence being established 
by such examination, that violence constitutes a crime, and if so, what 
crime, the testimony of witnesses to external facts and the law applied 
to those facts alone can determine. In technical language, whether a 
homicide has been committed or not is a medical question ; whether 
that homicide be justifiable homicide, or manslaughter, or murder, is a 
legal question. 
Briefly, then, the physical examination is the physician’s business ; the 
passing upon the admissibility of evidence and the laying down of the 
law is the lawyer’s. It would be as absurd and out of place for the 
latter to undertake to pass upon the very intricate questions of anatomy, 
physiology, pathology, and chemistry involved in the one, as it would 
be for the former to attempt to decide the equally delicate questions 
of law including considerations of the competency and validity of evi- 
dence, of the limits of self-defense, and of the nature and degree of 
crimes, which constitute the other. No lawyer is competent to answer 
the one, and no physician is qualified to answer the other; and a man 
understanding fully the nature and scope of his own piofession ought 
to shrink from assuming the dangerous responsibility of practicing an- 
other. Now, is it possible for one man to unite in his person the 
knowledge and qualities requisite for both ? Apart from human limita- 
tions I need point out only that science is armed with a microscope, 
while justice is blind ; that the mind and temper of a physical investi- 
gator and witness are not the mind and temper of a judicial officer, who 
never comes in personal contact with the facts, but receiving them from 
others calmly balances them and passes judgment; that a witness is and 
must always be to some extent a partisan, and that it is as improper to 
permit the medical witness to take the other evidence, as to permit any 
other witness to act also as judge. 
I am aware that when inquests are held and an autopsy is made, the 
coroner generally has some other physician to do it and be the medical 
witness; but in that case, the balance of the functions being wholly ju- 
dicial, it is not apparent why their discharge should not be entrusted to 
the usual agencies employed in the discharge of judicial offices, nor why 
a medical gentleman should be chosen to do a lawyer’s work. The ju- 
dicial functions do not properly begin until crime is suspected ; and 
when it is, the physician’s office, save as a witness, ceases. 
These considerations have brought me to the conclusion that the du- 
ties now performed by the coroner should be imposed upon, and the The Law of Coroners. 
9 
powers he now exercises should be vested in two distinct persons, one 
a medical man, the other a lawyer. 
I do not propose the subjection of the one to the other, but that each 
should perform the duties pertaining to his office, and proper to his pro- 
fession. The rooted inconsistency of joining these opposite duties has 
constituted the most formidable obstacle to progress. I propose, there- 
fore, now to dissever this incongruous union. 
Two medical officers should suffice for Boston. In the country the 
persons now serving as coroners would in many instances be the proper 
persons to act as medical officers. The medical officer should go to 
the spot where a dead body is found, and should decide in the first 
place whether or not the death resulted from natural causes, from an 
inspection and if necessary autopsy of the body, before making which 
he should call a number of persons to note the position and appearance 
of the body, which he will disturb by, the autopsy. He should make a 
written statement of his examination, — for the sake of greater accuracy 
and subsequent certainty, — and if he should find that death resulted 
from other than natural causes, he should at once notify the judicial of- 
ficer, who should thereupon proceed with the further investigation. Po- 
licemen and detectives could then, as they do now, “ work up ” the 
case, that is, gather all information to be acquired ; persons from the 
neighborhood would then as now interest themselves in assisting this 
search for facts, and thus there would be no want of witnesses. That 
useful executive officer, the policeman, who is almost always in charge 
before the coroner is notified and arrives, should be kept there to see 
that everything remains in statu quo} 
Of course you must make the judicial officer independent of the med- 
ical, so that in cases where the latter deems no judicial inquiry neces- 
sary, but such information reaches the former as to make him think 
otherwise, he may order the same or some other medical officer to 
make an autopsy, and may proceed with the investigation. The du- 
ties entrusted to these officers being of the greatest importance, we are 
undoubtedly all agreed that they must both be men of the highest char- 
acter. I count upon your unanimous assent when I say further that 
the duties to be performed by the medical man require for their proper 
performance more than average skill and special training. The loca- 
tion and appearance of wounds, whether so situated as possibly to be 
self-inflicted ; whether the condition and nature of wounds or abrasions 
indicate their infliction before or after death ; the position of the body 
with reference to apertures in the building ; the condition of the inter- 
nal organs ; the age and sex indicated by remains, — all these, and the 
1 The need of a public prosecutor— not to conduct proceedings already begun, but to put 
the machinery of the law in operation and see to the gathering of evidence — is becoming 
more and more clearly recognized ; at present this duty devolves upon no one, the police- 
men and detectives performing it chiefly of their own motion. 10 
The Law of Coroners. 
almost infinite diversity of anatomical, physiological, and chemical de- 
tails and questions that may arise in different cases require special ex- 
perience and minute and accurate knowledge. 
Most of the unfortunate blunders known as judicial murders have 
resulted from the inexperience or ignorance of the medical men en- 
gaged in the case either as witnesses or coroners undertaking to de- 
cide medical questions. Sometimes the consequences have been harm- 
less, comparatively, and the stories are amusing ; but too often they are 
tragical, and have a fatal termination. A few of these may serve to 
enforce this point. 
Marc Antoine Calas was the son of John Calas, a merchant of Tou- 
louse, aged seventy years, of great probity, and a Protestant. This 
son was twenty-eight years of age, of a robust habit, but of a melan- 
choly turn of mind. He was a student of law, and becoming irritated 
at the difficulties he experienced (in consequence of not being a Catho- 
lic) concerning his license, he resolved to hang himself. This he exe- 
cuted by fastening the cord to a billet of wood placed on the folding- 
doors which led from his father’s shop to his store-room. Two hours 
after he was found lifeless. The parents, unfortunately, removed the 
cord from the body, and never exhibited it to show in what manner his 
death was accomplished. The people carried the body to the town- 
house, where it was the next day examined by two medical men, who 
without viewing the cord or the place where death had been consum- 
mated declared that he had been strangled. On the strength of this 
the father was condemned and broken on the wheel. He expired with 
protestations of his innocence. 
Reflection came when it was too late. It was recollected that the 
son had been of a melancholy turn of mind, that his clothes were not in 
the least ruffled, that a single mark only was found from the cord, 
which indicated suicide by suspension, and in addition to these facts that 
the dress proper for the dead was found lying on the counter. Vol- 
taire espoused the cause of the injured family, and attracted the eyes of 
all Europe to this judicial murder. The council of state reversed the 
decree and vindicated the father’s mClnorv. 
On board a ship coming from Calcutta there had been a disturbance, 
and one of the sailors was said to have received a blow in the side from 
a handspike. Four months after this, and when he had been in port 
several days and was often on shore, he one day ate a large dinner and 
drank freely. He was taken ill and a physician was sent for, but he 
died before any aid could be administered. An examination took 
place ; the stomach was highly inflamed and still retained the food of 
the previous day. The liver was much diseased and there were numer- 
ous abscesses in it. The gall-bladder was natural. The fifth and sixth 
ribs were found to have been fractured so near the sternum as to occa- The Law of Coroners. 
11 
sion a slight depression of that bone, but union was so complete as to 
give no indication of the age of the fractures. The heart and lungs 
were sound. 
On these appearances the medical examiner gave it as his opinion 
that there was a probability that the fracture of the ribs had produced 
the diseased appearance of the liver, and that the influence of the latter 
had extended to the stomach. The persons accused of injuring the 
deceased were on this testimony committed by a justice of the peace to 
take their trial for murder. They were, however, soon brought up 
again on a writ of habeas corpus before two judges of the supreme 
court, and in the mean time the professor of anatomy in Harvard Uni- 
versity had made a further examination of the disinterred body. The 
stomach was found to contain a quart of undigested food, mixed with 
gin. Its internal surface was highly inflamed, particularly at the cardiac 
orifice. There were four or five ounces of fluid in the pericardium. 
In the liver were several tubercles, one of which had suppurated, but 
it had no connection with the fractured ribs. Indeed, the “ liver was so 
situated that it could not have been wounded by the fractured ribs with- 
out penetrating the diaphragm and the lower part of the lungs.” Yet 
these parts were sound. The blood-vessels of the heart were highly 
congested, the ventricles contained much serum, and there was a gen- 
eral dropsical effusion throughout the body. No other opinion could be 
given than that it was a case of general disease, induced by intem- 
perance, and that the immediate cause of death was the overloaded 
state of the stomach. The prisoners were in consequence discharged. 
In 1800, at the Devon assizes, Thomas Bowerman was presented to 
the grand jury for the murder of a bastard child by pushing an awl 
into its head. The body had been disinterred by order of the coroner, 
and on the inquest a hole was found on the side of the head near the 
ear, agreeably to the testimony of a witness. An Exeter surgeon, hear- 
ing of this case, attended the grand jury. He examined the skull, and 
found that the supposed hole was the natural perforation of a vein, and 
in proof of this pointed out a covering of enamel round the opening, 
which could not have been there if it had been made by force. In 
further illustration he exhibited several skulls all having similar perfora- 
tions, and each hole having a small channel, and the rim or edge smooth 
and polished. 
Mr. Alcock, some years ago, stated in a public lecture at London 
that he had known a fracture of the base of the skull produced by the 
awkward and violent tearing of the upper portion during autopsy, the 
saw not penetrating deep enough to divide the bones, and this was mis- 
taken by the inexperienced operator for fracture of the skull producing 
death. Being a criminal case, it might have led to melancholy conse- 
quences had not the error been detected by an observer. 12 
The Laiv of Coroners. 
Another case is related where one brother was supposed to have 
murdered another, and the crime' was after many years thought to be 
brought to light by the accidental discovery of the bones. Dr. Perfect 
examined them before the coroner’s jury and found that they were the 
bones of an aged female. 
Amusing instances of gross ignorance happen sometimes. In a case 
of supposed abortion, before a coroner’s jury in London, in 1829, a 
medical practitioner testified that the fullness of the breasts attendant on 
impregnation was the consequence of powerful medicines ; that the nat- 
ural opening of ducts about the os uteri were punctures, and finally, 
that the gall-bladder was filled with florid bile. For all of which the 
coroner's jury voted him their thanks. 
Of course in many cases it is the public interest that suffers from such 
official incapacity. Dr. Guy relates that he was summoned bv a coroner 
in a case where a woman previously in good health was seized with vio- 
lent vomiting in the night and died the next morning. The suspicion 
of poison was strongly confirmed by the swollen and crimson appearance 
of the body. A bloody, frothy serum issued from the mouth. She had 
complained of a burning sensation at the stomach, and had expressed the 
opinion before death that she had been poisoned. Dr. Guv refused to give 
any opinion as to the cause of death without the opportunity of a post- 
mortem examination. The coroner, who was not a medical man in this 
case, being in great haste to hold another inquest in another part of the 
city, and seeing the bloody serum issuing from the mouth, remarked to 
the jury that it was entirely unnecessary to open the body, that there 
was no doubt whatever that the woman died from rupturing a blood- 
vessel, and advised them to return a verdict to that effect, although an- 
other physician who was present testified his belief that the woman 
died from the effects of poison. The verdict of the jury was in accord- 
ance with the coroner’s recommendation. Being dissatisfied with such 
a flagrant dereliction of duty, Dr. Guy made known the facts of the 
case to the mayor, who caused the body to be disinterred, when it was 
satisfactorily proved that death had been caused by arsenic. Officers 
were dispatched in pursuit of the husband, but without success, as he 
had fled from the city, and thus in all probability a murderer escaped 
from justice. 
So far we have considered the medical officer. As to the judicial 
officer, he should be a man at least of the standing and ability of the 
district and municipal court judges. And in the language of that ad- 
mirable clause in our constitution, in order that these officers “ may be 
as free, impartial, and independent as the lot of humanity will admit,” 
they should hold their offices as long as the} behave themselves well, 
and should have honorable salaries, ascertained and established by stand- 
ing laws. This will rid us beyond peradventure of the unseemly rivalry The Law of Coroners. 
and race for fees which now occasionally occurs, and which cannot but 
tend to provoke scandal and bring into disrepute an important part of 
our judicial system. 
I come now to an important portion of my subject. Upon what of- 
ficer should this judicial function devolve? Should he be the person 
who subsequently has charge of the conduct of the prosecution, —I am 
speaking of cases where violence has been committed, for in none other 
is the judicial inquiry necessary, — or should he be a justice of some 
court ? 
You are aware, perhaps, that in France and in other countries of 
Europe the office of coroner is unknown. The prosecuting officer of 
the government — corresponding to our district attorney — proceeds to 
the place where a dead body is found, makes the investigation, sum- 
mons witnesses, and takes their testimony in writing, which is read to 
and signed by them. He has power to prevent egress from the prem- 
ises or departure from the neighborhood when necessary, to seize arti- 
cles and papers supposed to he connected with the crime. He is au- 
thorized to take with him one or two persons deemed by their art or 
profession capable of appreciating the nature and circumstances of the 
crime. 
In case a violent death is the subject of inquiry, or one where vio- 
lence is suspected, he is assisted by one or two health officers, who are 
always physicians, who report on the causes of death and the condition 
of the body. He is the person charged with the subsequent prosecu- 
tion of the crime as well.1 
However efficient this may be found in a system like that of France, 
it is hardly in harmony with ours. We cannot afford to leave out of 
account in our legislation the weaknesses and foibles of human nature. 
I have before adverted to a fact familiar to all who have much acquaint- 
ance with the administration of criminal law, that the tendency of a 
prosecutor is to become a partisan. Every district attorney, every po- 
lice officer, every detective, every person habitually engaged in the 
prosecution of crime comes in time to be less and less impressed with the 
truth of the proposition that every man must be presumed innocent until 
proved guilty. In him is represented the state, and the state is a party 
to the case ; a judge must be the free and unbiased repository of the 
interests of both. 
I reject, therefore, as unfeasible the proposition that the district attor- 
ney, having the later charge of the case, should also take the earlier 
evidence in a judicial capacity. If .you say that his being allowed to 
act thus would give him better possession of the facts of the case for 
his subsequent use, I reply he may be present, but not in a judicial ca- 
pacity. Let us beware how we make possible the union of prosecutor 
1 Teulet, Les Codes. 1860. 14 
The Law of Coroners, 
and judge, and create men more eager to convict than to do impartial 
justice. 
Being judicial, the duty should devolve upon a judge. I now pro- 
pose, therefore, to let the coroner’s court be merged in the criminal courts 
of first instance, called in the country district courts, in the cities police 
or municipal courts, and to transfer the judicial duties hitherto performed 
by the coroner to the judges of these courts. Being the first step in 
a judicial proceeding, all subsequent steps of which are taken in the 
courts, nothing can be more appropriate or logical than this transfer. 
Thus, and thus only, can you secure its proper place in a responsible 
and orderly judicial system. 
Nor is the proposed change as great as at first sight it appears. These 
courts perform now the identical duties performed by the coroner so far 
as he acts judicially, only they do it over again after the coroner in- 
stead of doing it once and for all. The judges of these same courts 
now do decide on their discretion whether a person accused shall be 
bound over for trial or discharged. So you are placing no more power 
in their hands than they now have. You risk nothing by the change 
and you get rid of a great danger. 
Let me call your attention to another view of the subject With 
anxious care and infinite solicitude we guard the life entrusted to our 
hands in a criminal trial. We employ the most august and elevated 
tribunal to preside over it, the highest law officer of the State to con- 
duct it; we allow the accused free choice of learned and able counsel 
to see to it that all the safeguards of the law surround and protect him. 
All this we do as well to do justice to the State as to abstain from doing 
injustice to the individual. Yet we entrust the first step in this pro- 
ceeding to random and irresponsible hands. And yet the first step is 
not infrequently the most important of all. “ Incompetent hands may 
destroy, untrained minds may overlook, the information which is readily 
obtainable at first, but once neglected is irreparably lost.” Consider 
the possibilities of imminent peril to endangered innocence, of hope- 
less loss to the security of the public here involved. 
In the country, where the district courts discharge the duties of courts 
of first instance, this change would involve no increase of judges or of 
expenditure. Their business does not occupy more than a few hours a 
day at the most. In Boston the municipal court performs these duties. 
There are three judges, and a special justice who sits in the absence of 
either of the others, in the city court. The suburbs have each a munic- 
ipal court, with one justice and two special justices. If we have not 
enough judges, one more at the most will suffice for Boston proper. For 
the district courts no increase or change will be required. 
There were held in Boston during the year ending April 30, 1876, 
one hundred and ten inquests and four hundred and twenty-three views, The Latv of Coroners. 
15 
costing the city the sum of $10,769.74. By comparison with previous 
years it will be seen that the amount is steadily increasing. This expend- 
iture included for medical examinations $1790, for chemists $170. This 
with the $4000 or more paid to jurors, constables, and scribes would give 
you enough to pay good salaries to two competent medical officers, and 
when you consider that no new judge is needed you have another 
$3500 at your disposal. The number of views and inquests just men- 
tioned is so largely in excess of the published facts as to give ground 
for the supposition that practices may now prevail which under a compe- 
tent and responsible medical officer would not occur, and thus the num- 
ber would perhaps be materially reduced. 
Now the coroner and jury must view the body, and the oath must be 
administered to the jury super visum corporis, and this, moreover, to 
quote an old English author, in order that the jury may have the ben- 
efit-of the coroner’s remarks upon the appearances which the body ex- 
hibits. 
As the proposed plan does away with the jury and gives the physical 
examination entirely into the hands of the medical officer, no good reason 
is apparent why the judicial hearing should be held on the spot, though 
there is probably no valid objection to that course. 
I have repeatedly referred to the want of responsibility of the exist- 
ing coroner. We, as attorneys, are responsible to the courts ; ministers 
are amenable to the discipline of their conferences ; there is no public 
servant who is not subject to some higher power for correction and re- 
moval. The coroner gives a bond for five hundred dollars, — less than 
a constable ; there is no penalty enacted for his misconduct in office, 
and the only way to remove him is by an address of both houses of the 
legislature to the governor! 
The power of the coroner to serve process and exercise other func- 
tions of the sheriff under certain circumstances is a relic of the remote 
past, when he was the sheriff’s substitute and deputy, and has now no 
ground or justification for being continued. These powers should at 
once be transferred to the sheriff’s deputies or to the sheriffs of adjoining 
counties. 
To recapitulate briefly. The changes proposed are: — 
(1.) To abolish the office of coroner as now constituted. The abo- 
lition of the coroner’s jury will follow. 
(2.) To divide its duties between (a) medical officers, to make the 
examination and testify to its results, (h) judicial officers, to receive the 
testimony and apply the law. 
(3.) To have the medical officers appointed bv the governor and 
council, during good behavior, and removable by the same power for 
cause shown. In Suffolk County there should be two, and they should 
receive fixed salaries. In the other counties they should be more nu- 16 
Recent Progress in Anatomy. 
merous (owing to the greater distances to be traveled), and should be 
paid by fees for the services rendered. 
(4.) To have the judicial duties performed by the justices of the 
criminal courts of first instance, as a part of a regular judicial proced- 
ure.