1703THE MEDICAL MAN AND THE CORONER.

THE LANCET.

LONDON: SATURDAY, JUNE 13, 1908.

The Medical Man and the Coroner.IT may be remembered by our readers that in the years

1903 and 1904 the heading which we have printed above thisarticle occurred very frequently in our columns, generallywith the addition of the word "Pathologist." During those

years we were engaged often in referring to the extraordinaryposition which was taken up by Mr. TROUTBECK, the coronerfor Westminster and South-West London, in connexion withthe giving of medical evidence in inquests which he held.Mr. TROUTBECK, it appeared, had assumed office on the under-

standing with the London County Council that he shouldadopt a policy recommended by the control committee of thatbody which obliged him to intrust the post-mortem examina-tions in all cases " of a special nature " to a specially skilledpathologist. So liberally did he interpret his mandate that-we quote from a letter by Mr. DONALD SHEARER in theJ’imes of June 9th-" between May, 1903, and February, 1905,Mr. TROUTBECK found it necessary to call in a specialpathologist, Dr. FREYBERGER, 816 times in place of the localor hospital medical attendant. During the same periodthe other seven coroners in London had between them

46 cases requiring special pathological knowledge. On

most, if not all, of these 816 occasions public moneywas wasted ; in not a few an erroneous verdict was

arrived at for want of accurate clinical information."

The justice of these remarks will be apparent to any fair-minded reader of many cases which we reported in 1903,cases in which the evidence of the medical practitioner whohad attended the deceased would have had obvious value in

correcting or corroborating post-mortem findings by clinicalobservations. In 1904 the legality of Mr. TROUTBECK’S

conduct was challenged, and many instances of the omissionof highly relevant evidence were reported to the LORD

CHANCELLOR by a joint deputation of the British Medical

Association and other societies which sought to call atten-tion to the dangers of the new procedure. It will be

remembered that Lord HALSBURY’S reply was a non

possumus, for in a letter dated July 29th, 1904, the

societies which had approached him were informed "thoughhis lordship’s present impression is not in favour of the

coroner’s practice, his lordship does not as yet see that

there is such a case as would found the exercise of the onlyjurisdiction which he possesses-namely, to remove a coronerfor misconduct in his office." The snub to Mr. TROUTBECK

had, be believe, no effect on him. ’

We should hardly have present occasion to re-tell this

story were it not that Mr. TROUTBECK has seen fit to

give a further exhibition of his attitude towards the

practice of medicine. It is true that in the former

controversy he was wont to protest that he was guided bystrictly impersonal motives, but his thinly veiled suggestions

that professional opposition to his innovation was the simpleresult of fee-hunger and his free attribution of "imper-tinence " to medical men in disagreement with him causeddoubts to arise as to his strictly judicial frame of mind.He may, of course, in his latest anti-medical dictum be againdisplaying strict impersonality, but his behaviour, while itcan bring serious grief into suffering families, appears on theface of it to be instigated by a desire to show that the fee-hungry medical profession is also actuated by murderousinstincts. The occasion for Mr. TROUTBECK’s activityagainst the medical profession arose as follows. It

appeared by the proceedings at an inquest that Sir VICTORHORSLEY had operated on a patient at the BolingbrokeHospital, from whom he removed a cerebellar tumour.

Three days after the operation the patient died, the

cause of death, for which a certificate had been duly given tothe registrar, being heart failure due to pressure which hadbeen previously exerted on the nervous system by the tumour.An inquest was held by Mr. TROUTBECK, before whom, inthe course of giving his evidence, Sir VICTOR HORSLEY

protested against the holding of an inquest in so plain acase. The jury returned a verdict of "Accidental death,"which the coroner suggested to them at the close of a homilywhich was virtually an attack upon the practice of surgery.Mr. TROUTBECK’S views on the progress of medicine ran

something as follows. He said that operations were muchmore frequent than they used to be and that clearly theywere to some extent the cause of the deaths that re-

sulted ; they could therefore not possibly be called

natural deaths and came within the Coroners Act of

1887 which made inquests imperative in such cases; and

he attempted, or is reported to have attempted, to clinchthis argument by saying that such was the opinion of all

coroners, It is hard to see how this statement can

be reconciled with the following passage from the reportof the Coroners Society for 1902-03: " In cases where

a patient has recovered from the effects of the aneas-

thesia, and the death was due to a necessary operationor the disease for which the operation was performed,an inquest is not required ; provided always that there isno allegation of neglect, serious rumours, or presumed wantof skill on the part of the operator, or that the friends ofthe deceased do not request an inquest for their satisfac-

tion." In this light any appeal by Mr. TROUTBECK

to his colleagues must appear unfortunate ; if he has

quoted them as being of his opinion he is not a veryaccurate person. We can imagine a medical coroner,

with some show of logicality, sitting to inquire into suchan event as a death after a surgical operation, if scientific

grounds appeared to warrant the inquiry, but how anyoneof Mr. TROUTBECK’S attainments, which may be enormousin the legal direction, could possibly guide a body of menlike a coroner’s jury to any sort of verdict upon the circum-stances of a surgical operation passes imagination.Mr. TROUTBECK’s departure shows him once again to be

ignorant of the spirit of the medical profession. Is he

correct in his legal interpretation of his duties ? The third

section of the Coroners Act of 1887 provides that where acoroner is informed that the dead body of a person is lyingwithin his jurisdiction, and that there is reasonable cause tosuspect that such person has died a violent and unnatural

1704 THE VALUE OF THE SURREY ISOLATION HOSPITALS.

death or has died a sudden death, of which the cause

is unknown, or "in such place or under such circum-

stances as to require an inquest in pursuance of any

Act," the coroner shall summon a jury. He would be a

zealot, indeed, who construed this language to mean that aninquest must be held in every case where a patient has notproved amenable to surgical treatment. If Mr. TROUTBECK

bases his contention on the fact that death in such a case is" unnatural " he would have to go further and say that the

cause of every death taking place after medical treatmentof any kind should be investigated by a coroners’ jury. It

is further implied in the Registration Act of 1874 that a death Ifrom disease under treatment secundum artem is not un- I

natural, and without such a safeguard medical practice wouldbe impossible. The more we reflect upon Mr. TROUTBECK’s

latest move the more he seems to have been instigatedby a simple desire to wound the medical profession whichcannot be got to regard him as anything but mischievous.Bat the public will suffer if Mr. TROUTBECK has his wayeven more than the medical profession. Mr. TROUTBECK

will not be able to persuade juries that medical men operatefor the love of giving pain and from lust of gold, regardlessof the true needs of the patients ; and the distress caused bythe publicity of unnecessary inquests to many families in

the first grief of a bereavement will be extreme.

The Value of the Surrey IsolationHospitals.

DR. EDWARD C. SEATON, the county medical officer of

health of Surrey, has recently issued an interesting andinstructive report with reference to the effect of the opera-tion of isolation hospitals and compulsory notification in that

county upon the behaviour of scarlet fever, and in his

investigations he has been ably seconded by Dr. JOHNWILLIAMSON who has conducted some original and valuableresearches upon the subject. As a frontispiece to the

report is a chart showing the death-rate from scarlet fever

per 1,000,000 of the population in England and Wales from1856-1906, and this chart brings out the now well-knownfact that a marked decline in the death-rate of the disease

had commenced prior to the general provision of isolation

hospitals and long antecedent to the introduction of com-pulsory notification. This circumstance is obviously one of first-rate importance in a consideration of the influence ofisolation but it is nevertheless easily possible to over-

estimate its value. Question at once arises as to what

this decline in the death-rate really means. Does it implydiminished prevalence of the disease, or may it be that whilethe disease itself is becoming far less virulent its actual

prevalence is as great as, or even greater than, before 2 This

question is very difficult, if not impossible, to answer,

inasmuch as antecedent to notification we had practically nodata as to prevalence, and even with notification we must becareful in generalising. Increase or decrease in the number

of notifications may really mean nothing more than a sort of

systole and diastole of the type of the disease-at one periodeasily recognisable, at another only so with difficulty. Again,our medical practitioners may be becoming more expert inthe recognition of the disease than formerly.

It must, nevertheless, be said that the evidence in favour of

a diminished fatality-rate of the disease during recent times.is very strong-indeed, practically conclusive, and the ques-tion to be asked is, How far is such decrease to be attributedto the operation of notification and isolation? Before an

answer could be found to this question it would be desirableto investigate the behaviour of scarlet fever in countrieswhere there are practically no isolation hospitals, but.

as Dr. SEATON has not gone into this aspect of

the question we shall not do so ourselves; and it.

has certainly to be admitted that in the present unsatis-

factory condition of statistical returns in almost every other

country but our own journeys into international figures are.perilous undertakings likely to lead to inferences of a far-

reaching but not improbably mischievous and misleadingcharacter. In so far as Surrey is concerned, Dr. SEATON con.cludes that isolation and notification have had an influence

in the reduction both of the death-rate and the fatality-rate of scarlet fever, but he does not find it possible todetect how far, if at all, the attack-rate has been influenced-i.e., it cannot be shown, he thinks, that the preventivemeasures taken have materially affected the notification

case-rate. He finds, in fact, that there is 11 neo very obvious

correspondence between the hospital isolation and the

prevalence of the disease." The fact that there is "some-

what less scarlet fever in a district with isolation accom-

modation than in the same district without " is, of course,as Dr. SEATON recognises, not very convincing as to the

value of isolation hospitals, and it is at this stage that Dr.WILLIAMSON’S investigations may be usefully introduced.He has at considerable pains investigated the history

of all notified cases in the Epsom and Dorking combineddistricts from 1891-1905 and his results are presented inthe form of charts, " hospital " and " home treated casesbeing depicted separately and, by way of eliminatingthe possibly disturbing factors of good class houses, hehas dealt with cottage cases only-i.e., cases where the

opportunities for proper isolation were clearly remote. The:

general conclusions brought out by these charts are thosewhich we have on many occasions predicted in these

columns-i.e., that the major damage as regards the

infection of other persons is brought about before the

first case has been recognised, notified, or sent to hos-

pital, and that consequently the influence of isolation.

hospitals is less than had at one time been anticipated.Dr. WILLIAMSON’S" hospital" charts indicate that a veryhigh percentage of secondary cases were infected before the.removal of the first patient; they show, indeed, that some-where about two-thirds of the secondary cases are thus to be:accounted for. The charts, however, bring out the instruc-tive and consoling fact that the advantage as regards the:avoidance of secondary cases is always on the side of the

hospital until after the seventh week from the occurrence ofthe primary attack when the so-called "return" cases-

begin to appear and, seemingly, influence the "hospital"’chart to a materially greater degree than the "home chart..As Dr. WILLIAMSON concludes, " it is plain, therefore, fromthe above charts and figures that an earlier discovery orrecognition of cases is necessary to make hospital isolation.fairly effective."There is no doubt, as we have for years past urged, that it..

is the unrecognised case which governs the situation both as.