901THE MEDICAL MAN, THE CORONER, AND THE PATHOLOGIST.

The Medical Man, the Coroner, andthe Pathologist.

THE LANCET.

-LONDON: .STURDA; MiRCH,8, 1903.

WE publish in another column a paper by Dr. H. H.

LITTLEJOHN, which criticises the system under which

inquests are held and discusses at some length the questionof the efficient performance of post-mortem examinations

made by order of the coroner. No one contends that

the inquiries antecedent to the holding of an inquestare made by such persons or in such a manner as

to insure the holding of inquests in all cases where

inquests are ordered by the law ; and the majorityof our readers will assent to the proposition that the

cause of death should always be established by a

medical man before the burial of the body is permitted.We hold the view that a post-mortem examination

should be made in all cases where doubt exists which

cannot otherwise be resolved, but we are not in accord

with Dr. LITTLEJOHN when he discusses the competencyof medical practitioners in general to conduct the necropsieswhich the coroner may deem it necessary to order. The

writer’s position and experience give weight to his opinionsand being anxious to see all the aspects of the questionventilated we have pleasure in affording to his paper the

hospitality of our columns. We are not, however, able to

accept as matters of universal experience, in England atany rate, all the facts with which his individual observa-

tion has supplied him and from which he draws his

conclusions.

The views which we have ourselves expressed upon the

provisions of the Coroners Act of 1887 for the calling ofmedical witnesses and the holding of post-mortem exami-nations for the purposes of that Act do not implyany opinion on our part that the sections in questicn are

perfect or that they might not after due consideration be

improved. We have, however, pointed out what those sections

lay down and have urged that any alteration in the practiceprescribed should be brought about by Act of Parliament,after discussion in both Houses and after the advice of

the leading members of the medical profession has beenheard, and that radical changes should not be made bycoroners or by local bodies influencing the action of

coroners. The action of individual coroners, some of

whom are medical men and some of whom are lawyers,and all of whom are subject to the influence of

their own opinions, cannot produce the certainty and

consistency which are to be desired in such matters.

Under the existing law provision is made in terms which weneed not repeat for the making of post-mortem examina-tions by local medical men who in ordinary circum-

stances will be general practitioners admittedly of varying

qualifications and ability. Provision is also made for the

obtaining of further expert assistance should the cause ofdeath appear not to have been ascertained fully by those

primarily ordered to be employed. Dr. LITTLEJOHN appearsto consider that the incapacity of general medical prac-

titioners as a body is such that they should never

be intrusted by coroners with post-mortem examinations,and we lay his statements of fact with his deductions

before our readers. Like ourselves they may fail to re-

cognise as typical of the medical practitioner °° an excellent

physician" who "has never made a post mortem in his

life," and may question the accuracy of the assertion that

"very few" students when they obtain their qualification11 have personally performed a post-mortem examination."With regard to this, moreover, we submit that if medicalmen having obtained their right to enrolment upon the

Medical Register are not qualified to make ordinary post-mortem examinations with efficiency a defect has been

exposed in the course of training adopted in medical

schools which is not beyond remedy and which should bemade good.

In the course of his paper it will be observed that Dr.

LITTLEJOHN gives instances of actual necropsies and theirresults. Some of these support the propositions with whichfor the moment he is dealing but hardly lend force to othersof which he treats elsewhere. We may be, for example,in accord with him when he says that ’’ the external

inspection of a body can seldom give a true indica-

tion of the cause of death in cases where persons are

found dead" ; but we should hardly select the case which

he cites of carbolic acid poisoning to support the contention

that a specially qualified and appointed pathologist is neces-

sary in order that post-mortem examinations may be

efficiently held. In such instances as these the coroner

would fail in his duty if he neglected to hold an inquestand thus to establish the cause of death, and the nearestmedical practitioner would deserve all that Dr. LITTLEJOHNsays of him if he failed to supply the necessary information

after making the examination intrusted to him. If in cases

so simple, or in others of greater complexity, the medicalman does not express himself with certainty before the

coroner’s jury it is for the jury to ask for further assistance.We are not aware that medical men are in the habit of

expressing themselves as sure when they are not sure or

when they have no good cause to be sure, and we

do not admit, as Dr. LITTLEJOHN would have us do,that "the majority of medical men engaged in generalpractice are not fitted to conduct medico-legal post-mortemexaminations." We admit, however, on the one hand, thatin certain cases an expert is necessary, while on the other

we maintain that in the great majority of cases which comeunder the notice of the coroner the medical practitionerwho attended the deceased during life is the one who

should perform the necropsy. His knowledge of the

previous history of the case will lead him especially to

investigate certain points which an expert not possessing afull acquaintance with the clinical features observed duringlife might pass over. We see no analogy between this

and the patent absurdity suggested by Dr. LiTTTLEjOHX as aparallel-namely, ’’ that the physician who attends a patientduring the onset of an attack of appendicitis is the best

902

person to operate when surgical interference becomes neces- I

sary." The whole matter is one which deserves full dis-

cussion and the careful consideration of the facts and

arguments put forward on both sides. For this reason

we welcome Dr. LITTLEJOHN’S able exposition of views

from which we differ.

The Recent Debates on the Navyand Army Estimates.

THE attention of the House of Commons and of the countryhas been much absorbed of late with naval and militarymatters in general and with the navy and army estimates in

particular. The national expenditure has reached enormousdimensions, as everybody knows, and it is to be feared that so

long as foreign Governments show no signs of exhaustion butare pressing forward in these directions so long shall we be

compelled for the security of this Empire to do the same.What we have to look forward to in the future is, let

us hope, the realisation of a strong Empire every partof which is organised to take care of itself. All

political parties are agreed on the supreme necessity of

keeping up a large, preponderating, and highly efficient

navy and are prepared to vote ungrudgingly any sum of

money that may be necessary for this purpose. The nation

seems to be generally satisfied, on the whole, with the way inwhich the money is spent in this direction, with the systemof training of the officers and men, and with what is beingdone towards still further developing the efficiency of thesenior service. With the army, however, the case is different.

Although we do not believe that there is in reality an un-

willingness on the part of the nation to bear any financialburden that can be shown to be absolutely necessary, manypeople seem doubtful, amid so many conflicting views,whether the measures proposed to be taken by the Govern-ment are the wisest and best that can be devised. Happilythese are matters, in their broad conception, for the con-

sideration of statesmen and quite outside the province of amedical journal. There are points, however, which invitethe attention of THE LANCET.

The debates in Parliament during the present monthstarted on a motion relating to the training of officers

and men. Mr. BRODRICK, in reply to Colonel LONG andMr. LEE, gave a sketch of his new system for the entranceand training of officers for the army. Recourse will still

be had to the channels through which these have been

hitherto supplied-namely, the usual competitive examina-tions, the militia, and the universities-but the presentsystem will undergo some radical modifications. An AdvisoryBoard is to be constituted which is to say the final word

in regard to military examinations and some entirely fresh

proposals are made with the object of attracting a largelyincreased number of university candidates into the army.

We have nothing to say against the appointment of a

director-general of military education or as to the representa-tives who are to constitute the proposed Advisory Board.But Mr. BRODRICK seems to be quite enamoured with theidea of examination being an effective test and with a

system of doing things by councils, committees, and advisoryboards. Everything connected with army administration is

apparently to be carried out in future through their instru-mentality and little or nothing is to be left to the responsi-bility of heads of departments. It would seem to us that

this almost exclusive method of transacting public businessis rather a sign of official weakness than an indication of

strength and directness of aim and purpose. While we

recognise that, as regards the Army Medical Service, for

example, an advisory board strengthens the hands of theDirector-General rather than otherwise, Mr. BRODRICK

appears to intend that the functions of the Advisory Boardshould leave little, if anything, to be done by the responsiblehead of the Army Medical Service.

The proposals for raising the educational standard with

a view to improve the quality of those seeking to serve

in the commissioned ranks of the army form a large anddifficult subject. As regards university candidates the pro-posals strike us as excellent in their way. We question, how-ever, whether these proposals, including the taking of anhonours degree in military subjects, will practically provelargely successful in attracting university graduates. The

intention is, we presume, that the army is henceforth to betaken seriously as a profession like any other profession,but no prospect is held out for any increase in the presentrate of an officer’s pay. The army, consequently, as a careercan only prove attractive to those who have a decided tastefor military life and adventure and are possessed inde-

pendent means. To all such it will, no doubt, always holdout great attractions, as it has done in the past. But

whether it can be made to offer inducements to the man

who is before all things a scholar we feel doubtful.

And with such candidates for commissions the passingof a medical examination may occasionally introduce

a difficulty which will have to be carefully providedagainst. A course of hard reading for an examination

does not always prove conducive to good health or

perfect eyesight And although it goes without sayingthat intellectual training counts for much in the army as

elsewhere, it is not everything. In the making of great andsuccessful generals there is a rare combination of qualities-of character, courage, and temperament, as well as of

mind and knowledge ; great generals are usually born notmade.

With regard to the men forming the rank and file of the

army it is contended that with the present arms and modernmodes of warfare the soldier is called upon to exercise

his judgment and intelligence far more than he was in

the past or under military systems of automatic training,such as have more or less obtained since the days of

FREDERICK THE GREAT. Hence we want to improve the

quality of the men who enlist and here we have a chronic

difficulty. There cannot be an army without soldiers anymore than a river without water, and how the desired

number of recruits of the requisite standard of health

and physique for soldiers is to be obtained is puzzling all

military experts who recognise the difficulties of conscrip-tion in this country. We have only to take note of

the large number of recruits rejected on medical inspec-tion and of the number of would-be soldiers who are

prematurely discharged as medically unfit for the service-a fact to which attention was recently called in the Houseof Lords-to see that there is something radically wrong

903

in regard to the feeding, housing, physical training, and

personal hygiene of the classes whence they spring. We

have already dwelt, however, upon this aspect of the casein connexion with what General Sir FREDERICK MAURICE

has written thereon and there is no need to discuss it again.We do not, as our readers know, think that the

Government adopts the best means or makes the best

use of available methods for improving recruiting. The

most powerful incentives to enlistment, except in time of

war, are, we regret to say, want of food and want of work.Once in the army it is marvellous what brave, good, un-selfish men our soldiers show themselves. After all is said

and done, it must be remembered that the regulars did thehard marching and the hard fighting of the late war in SouthAfrica. We have no sympathy whatever with those whoseek to belittle them, their work, or the sacrifices which

they are called upon to make-and always do make-noblyand cheerfully.

Rex v. Klosowski.ON March 19th SEVERINO KLOSOWSKI, alias GEORGE

CHAPMAN, was after a four days’ trial convicted

and sentenced to death at the Central Criminal

Court for feloniously killing MAUDE MARSH, a youngwoman with whom he had cohabited. The history of

the particular crime and its associated circumstances

render it one of considerable interest whether cen-

sidered in its medico-legal or purely forensic aspects.KLOSOWSKI came to England in 1888. He married a Polish

woman whom he afterwards left. In 1895 he induced a

young woman named ANNIE CHAPMAN to live with him ; herhe abandoned after betrayal. Probably it was his liaison withCHAPMAN that led him to assume her name, by which he wasknown until the case of MAUDE MARSH came to be investi-

gated. In 1897 he resided at Hastings with a married

woman named ISABELLA SPINK who passed as his wife. In

1898 SPINK died. Whilst at Hastings KLOSOWSKI purchasedfrom a druggist an ounce of tartar emetic. The label of the

packet was found at the prisoner’s house after the death ofMAUDE MARSH. After SPINK’S death he was supposed tohave gone through a form of marriage with BESSIE TAYLOR.

She, too, sickened and died. It is noteworthy that the

symptoms exhibited by SPINK and TAYLOR were of

practically the same character, but poisoning was not

suspected, for the death in one case was certified as phthisiswhilst in the other obstruction of the bowels was assignedas the cause. The certificates clearly referred to the pre-dominant or ultimate symptoms-persistent vomiting andexhaustion.

In February, 1901, BESSIE TAYLOR was attended in herfatal illness by Mr. J. M. STOKER. Rendered callous, nodoubt, by his previous fortune in escaping detection,KLOSOWSKI called in Mr. STOKER to minister to his last

victim, MAUDE MARSH. It is not necessary to narrate the

tortuous record of the murderer. He was proved to havecompassed the deaths of three women by chronic anti-

monial poisoning. He abandoned his own wife, ruined

the life of one of his paramours, and when tardyjustice overtook him at last was seeking to possess himselfof yet another woman. Counsel for the defence pleaded

the absence of probable motive, but this was effectively metby the Solicitor-General who pointei to the one dominat-ing feature of KLOSOWSKI’S character, "cruel, pitiless lust."It is not too much of a refinement to assert that althoughlust was the prime agent in directing his actions the prisonerwas probably endowed with a peculiar form of pervertedsexualism, for even if his unbridled passion may havedriven him to sore straits a further explanation is requiredto account for his ruthless sacrifice of human life. Intel

lectually, no doubt, he was sane, but morally, in a partialdegree, he must be accounted so far removed from the

base-line of sanity as to verge on "alienism. We do not

for one moment argue criminal irresponsibility in his

case, for this would carry us far beyond what is warrantedeither by empiricism or experience on medical grounds,whilst it would be subversive of justice. As the law exists

death is the only fitting requital for such merciless deeds.

Apart from considerations of KLOSOWSKI’S mental and

moral state the most interesting feature of the terrible

story from a medico-legal point of view was the condition inwhich the body of one of his alleged previous victims wasfound. Although it had lain in the grave for somethinglike four years it was preserved from decomposition in

a marvellous degree. This, of course, was attributable

to the effects of antimony. A similar state of the

organs was found in the case of ANN PALMER, the wife

of the Rugeley murderer. Here after 15 months’ inteiment

antimony was detected even in the ovaries and uterine walls.Anyone would think that from the considerable knowledgeof the properties of drugs possessed by KLOSOWSKI he wouldhave lived in mortal dread that his sins-if he had anyconsciousness of the quality of sin-though hidden in the

grave, were being kept for his undoing by the very agentwhich he had used to destroy life.We must take exception to some criticisms upon

the medical profession passed by Mr. Justice GRANTHAM

who tried the case under consideration. It is not the

first time that Sir WiLLiAM GRANTHAM has delivered

himself of uncomplimentary opinions of the medical

profession. No doubt his legal mind was disquietedby the fact that antimonial poisoning may be so easilymistaken for natural disease. It does seem strangeat first sight that the result of the action of antimony onthe animal system should so closely simulate the evidenceof natural illness that even a skilled observer may not have

his suspicions aroused, but so it is. Moreover, a medicalman does not approach his patient in the guise of a

criminal detective. This is not the first occasion on

which several people have died at short intervals from

antimonial poisoning without the fact having been broughtto light save after a protracted period and then, so to speak,only by an accidental occurrence which pointed to certainpossibilities. In REG. v. WINSLOW, tried at the Liverpoolautumn assizes in 1860, it appeared that three members of afamily had died and had been buried in suspicious circum-stances. On exhumation antimony in small quantities wasfound in their bodies, but scientific evidence was not pre-pared to vouch that the antimony caused death. The

symptoms of a disease are not seldom anomalous and

those induced by antimonial poisoning may vary coa-

siderably. In THE LANCET of May 22nd, 1847, p. 535, isrecorded a case where a young man swallowed two drachms

904

of tartar emetic in mistake for Epsom salts. Half an hour Ilater he vomited once. Mustard was required to bring onemesis and gradually the symptoms abated and the patientrecovered. In the case of poisons producing such capriciousresults it must be very difficult to detect their use with cer-

tainty. One remark made by Mr. Justice GRANTHAM was

timely in view of the report of the committee appointedto consider and to draft regulations for officially per-

mitted cremation. 1 Had the bodies of ISABELLA SPINK and

BESSIE TAYLOR been cremated the real cause of death and

KLOSOWSKI’S participation in it would never have been

revealed. It is questionable, however, if those bodies

would have been reduced to ashes had the safeguards nowrecommended been in force and of these safeguards Mr.Justice GRANTHAM appears to be in ignorance. We proposeto deal more exhaustively with this question at an early date.We cannot close this notice without expressing our con-

gratulations to Dr. T. STEVENSON on having accomplisheda masterpiece of toxicological investigation and to the

medical men through whose instrumentality the murderscame to light.

Annotations.

A NATIONAL TRAINING SCHOOL FOR MIDWIVES.

" Ne quid nimis."

IN a letter to the Times of March 17th, signed by LadyGeorge Hamilton and Miss Gregory, a proposal is made

to establish a general hospital with a maternity annexe inone of the densely populated outlying districts of London asa national training school for midwives. In this institution,it is suggested, educated gentlewomen should receive an

eighteen months’ course of instruction in general and monthlynursing and then a six months’ course of midwifery in

the hospital and district. Having passed their examina-tions they would be drafted out as midwives to wherever

they might be required, and they would return to the

hospital every third year for re-instruction and re-

examination. The scheme is put forward because, as thewriters of the letter contend, the country has, in virtue

of the Midwives Act, ’’ undertaken to remove by degrees ahighly responsible and scientific profession from the handsof uneducated women." " They do not think that the

country should rest satisfied in returning the work to

the same class of women after they have received a

minimum of training. We are in entire agreement withthe view that midwives should receive some trainingin general nursing besides the special training which theyreceive in lying-in hospitals, and we hope that the newMidwives Board may find it possible to lay stress uponthis point. It is also important that no difficulties shouldbe placed in the way of any women who may intend to

become midwives under the new Act obtaining the necessaryinstruction and training under the best conditions. It is

possible that the present lying-in hospitals and trainingschools may not be able to deal adequately with the

increasing number of persons who may be expected underthe new Act to enter for a course of training as midwives. It

is, however, of importance that this should be clearly shownbefore any measures to add to the already excessive numberof small hospitals in London are carried out or, indeed,initiated. We must confess to some doubts as to whether

any great number of educated gentlewomen will be foundto take up an occupation which. in existing circumstances

1 See THE LANCET, March 17th, p. 673

must be but poorly paid and in which there are but

few opportunities of their reaching such positions as

are open to the ordinary general nurse. It -would be

little short of a calamity if the scheme led to the

formation of a class of superior midwives who would

tend to enter into competition with the medical men in thepoorer districts and who would be inclined in view of their

better and no doubt more expensive training to charge feesapproaching those charged by duly qualified medical practi-tioners. With the object of the two signatories of the

letter in their endeavour to improve the training of midwiveswe are in entire sympathy, and if educated gentlewomen canbe persuaded to take up the occupation so much the

better for all concerned ; but if the scheme is to leadto the formation of a class of nurses who will considerthemselves something more than ordinary midwives, andwho must be something considerably less than dulyqualified medical practitioners, then it cannot fail to do

harm. It would be interesting to hear what in the opinionof Lady George Hamilton and Miss Gregory is an adequatefee for adequate attendance" which they say the majority"of those requiring the services of midwives who are not

paupers but the wives of self-respecting artisans andlabourers are thankful to pay." By all means let us striveto improve the status of the midwife, but let us alwaysremember that the most highly trained midwife must beimmeasurably inferior in her amount of knowledge to thequalified medical man. It is to be hoped if any such schemeis adopted that it will be carried out with the consent of thecouncil of King Edward’s Hospital Fund for London andwith the concurrence and advice of the new Midwives Board.

SIR E. CASSEL’S GIFT FOR THE RELIEF OFOPHTHALMIA IN EGYPT.

As has already been announced in our columns, a meetingwas held recently at the office of the Egyptian Sanitary

Administration at Cairo to consider the question of the

disposal of Sir Ernest Cassel’s gift of 40,000 for the reliefof ophthalmia in Egypt. At this meeting a scheme wasformulated by Sir Horace Pinching, the head of the depart-ment, for the institution of an " Ambulatory Dispensary."It is understood that the annual income from Sir Ernest

Cassel’s splendid gift will be about .f.1760. With this moneySir Horace Pinching proposes to create an additional postof inspector and to engage an oflicer for a short term of threeyears or so to give special attention to diseases of the eye andto travel round the provinces with a tent, so that the patientswould not have to travel any distance to be treated. The

inspector is to work for two months in the provinces and thento be for one month in Cairo, alternating his systematic visitsto the provinces with a sojourn in the capital. Sir Horace

Pinching’s scheme is only tentative ; it will require the

sanction of Lord Cromer and, we presume, the approval ofSir Ernest Cassel before it is put into action. We think,therefore, that it will be well to state now that serious

objections have been formulated to the scheme. A letter,a copy of which has been sent to us, has been addressed to

Sir Ernest Cassel from a prominent member of the medicalprofession who considers that the scheme is a practicallyuseless one and who gives his reasons for his critical atti-tude. "All they propose doing," he says, speaking of thesanitary administration, "is to purchase and equip one tentwhich, with its maintenance and salaries, leaves a wide

margin on the interest derived from the sum. It is towork solely in the provinces and not to touch the towns.The tent of itself is sufficient to nullify utterly anypossibility of good result, as it is a most unsuitableerection only justifiable in the stress of war, and any re-search work or other work of value is quite impossible in it."We doubt whether this criticism is wholly accurate, as the