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Title: Observations on Coroners
Author: Hewitt, William, active 19th century
Language: English
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*** Start of this LibraryBlog Digital Book "Observations on Coroners" ***
Transcribed from the [1852] Samuel Daynes edition by David Price, email
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OBSERVATIONS
ON
CORONERS,
BY
WILLIAM HEWITT, SURGEON,
NORTH WALSHAM,
Author of an Essay on the Encroachments of the German
Ocean, with a design to arrest its further depredations.
* * * * *
“_Unius ætatis sunt quæ fortiter flunt_, _quæ_
_pro utilitate scribuntur æterna_.”
* * * * *
PRINTED FOR THE AUTHOR,
BY SAMUEL DAYNES, SAINT STEPHEN’S STREET, NORWICH;
SOLD BY JOHN CHURCHILL, MEDICAL BOOKSELLER, PRINCES’ ST.,
SOHO, LONDON;
OURY AND CO., LONDON ST., NORWICH;
JOHN MOWER, NORTH WALSHAM, AND ALL BOOKSELLERS.
Entered at Stationers’ Hall.
* * * * *
_To the Right Honourable The Secretary of State_, _for the Home
Department_.
SIR,
The importance of the subject, I humbly anticipate will be sufficient
excuse for the liberty I have taken, in dedicating to you the result of
my experience connected with Coroners’ Inquests.
The instances narrated with reference to apparent delinquencies, in
non-medical Coroners, contained in the following pages, occurred in my
immediate neighbourhood, and may be believed, as resting on the brow of
truth. Yet I most heartily coincide in acknowledging the integrity and
worth, of Gentlemen pursuing vocations, for which they have alone been
amply educated; and it is only when they assume a position, or accept
office to execute duties they are incompetent to perform, as is
frequently observed, that I deem it my duty to wield my pen against such
appointments: not less for the sake of humanity, than for the dignity,
and I might add, the disregarded importance of the medical profession, to
which I have the honor to belong.
I am, Sir,
Your very humble and obedient Servant,
The AUTHOR.
OBSERVATIONS ON CORONERS.
“If there’s a hole in a’your coats,
I rede you tent it:
A Chield’s amang you, taking notes,
And, faith, he’ll prent it.”
IT is no inglorious vanity in Englishmen to consider the laws of their
country afford an example for other nations to follow. Founded on the
lasting rock of integrity, shewn in the strict regard for the liberty of
the subject, they command the obedience and the admiration of thousands.
But events, as they transpire, unfold the humiliating circumstance, that
blemishes dimly seen in the distance become prominent on the near
approach of extending knowledge; thus disclosing the fact, that this is a
progressionary as well as a probationary world in which we live, and that
perfection in human institutions cannot be attained, unless, through the
power of an Infinite Being, the mortal in his earthly career be permitted
to assume immortality.
Trial by jury appears the great feature by which the laws are regarded;
and a better test for its usefulness cannot be pourtrayed than when with
becoming dignity, discrimination, and foresight, it is employed to search
into the cause of the death of a fellow creature; consequently no judge
in the lands hold a higher position than a coroner, for almost unlimited
power is allowed, perfectly in accordance with the sacred trust imposed
upon him. But the responsibility attached to office, involves duties of
extraordinary character; and the public have a right to expect that
efficient pains-taking persons should be appointed, so that enquiries
should be conducted in a clear, straightforward, impartial, manner;
otherwise innocence might be tarnished, criminals might escape, and
laws—coeval with life, framed for its protection—might be considered
non-entities.
Coroners are officers at common law, because they deal principally with
the pleas of the crown; and, possibly, the name may be derived from the
manner of holding the inquest in _corona popupuli_. The Lord Chief
Justice of the Queen’s Bench is, by virtue of his office, principal
coroner of England; and may, if he pleases, exercise the jurisdiction of
coroner in any part of the realm. In former days they were the principal
conservators, and principal magistrates, within their counties, and they
may now bind to the peace any person who make an affray in their
presence.
The office of Coroner is of great antiquity, for in the days of Alfred,
King of England, they existed, for he punished with death, a judge who
sentenced a party to suffer death upon the coroner’s record, without
allowing the culprit to traverse or be tried in another court. Coroners
were ordinarily made by grant or commission, without election—such are
the coroners of particular lords of liberties or franchises, who by
charter, have power to create their own coroners, or to be coroners
themselves. Thus, the Lord Mayor of London, is by charter of 18 Edward
the Fourth, Coroner of London. The Bishop of Ely also has power to make
coroners in the Isle of Ely, by charter of Henry the Seventh—Queen
Catherine had the hundred of Colridge granted her by Henry the Eighth,
with power to nominate coroners.
The Cinque Ports {7} have their own coroner. The Dean and Chapter of
Westminster have their own coroner, who by their appointment, is coroner
of the city and liberties of Westminster. The Wardens are coroners of
the Stannaries in Cornwall. The Master of the Crown Office, or Clerk of
the Crown, is Coroner of the Queen’s Bench, and has jurisdiction over
matters arising within the prison of that court and Marshalsea. He holds
his office by letters patent, under the great seal. In addition to
which, there are many exclusive jurisdictions and corporations, for which
coroners are appointed.
In each of the twelve shires, in Wales, and Cheshire, &c. there are only
two coroners, which are settled by stat. 33 H. 8, c. 13 and 34 H. 8, c.
26.
But the two principal jurisdictions over which by the King’s grant,
coroners may be appointed, are those of the Admiralty and the Verge.
At common law, if any felonies or treasons were committed within any
creek or arm of the sea, which was in the body of the county, the common
law courts had jurisdiction; but by stat. 15 Richard 2, c. 3, it was
provided, that in “case of the death of a man or mayhem, done on great
ships hovering in the main stream of great rivers only beneath bridges
nigh to the sea, the admiral shall have cognizance of the same rivers.”
It is said that his jurisdiction extends only to rivers that are arms of
the sea, namely, that flow and re-flow, and bear great ships. When the
haven, &c. is within the body of the county, the common law tribunals
have a concurrent jurisdiction, and the Coroner of the County as well as
of the Admiralty, may take inquisition of deaths, &c. happening there.
Therefore, when a man-of-war was _infra corpus comitatus_, the land
coroner was holden to have jurisdiction; and if the captain refuse the
coroner admission, on board, the court will grant an information.
Again the Admiralty jurisdiction extends only to such deaths, &c. as
happen in great ships, and not to such as occur in small vessels.
When the jurisdiction of the County and of the Admiralty is concurrent,
the coroner who first seizes the body, is entitled to take the
inquisition; and if he proceed to do so, the authority of the other is
determined.
The other great jurisdiction is the Coroner of the King’s House, usually
called the Coroner of the Verge, who it seems anciently was appointed by
the King’s letters patent, but by stat. 33 H. 8 c. 12, the granting
thereof, is settled in perpetuity in the Lord Steward, or Lord Great
Master of the King’s house for the time being.
Anciently the Coroner of the Verge had power to do all things within the
Verge belonging to the office of the Coroner, to the exclusion of the
Coroner of the County; but because the King’s Court was often moveable,
it is ordained by stat. of Articuli super Cartas, c. 3, that on the death
of a man, the Coroner of the County shall join in inquisition, to be
taken thereof, with the Coroner of the King’s house, and if it happen it
cannot be determined before the Steward, process and proceedings shall be
thereupon had at common law.
But yet in the case of death within the Verge, the Coroner of the County
cannot take an inquisition without the Coroner of the Verge; and if he
does it is void, but if one person be Coroner of the County, and also of
the Verge, the inquisition before him is as good as if the offices had
been in several persons and taken by both. And though the court remove,
yet he may proceed upon that inquisition as Coroner of the County.
Beside those above enumerated, there are particular coroners for each
county, who hold their offices (virtuta electionis) in pursuance of the
statute 3 Edward I. c. 10, wherein it is provided, that “through all
shires sufficient men shall be chosen to be Coroners, of the most loyal
and wise knights,” which _know well_ and _may best_ attend upon such
offices, and “which lawfully and shall attend and present pleas of the
crown.” Therefore the election of a coroner, is by the freeholders of
the county, in pursuance of a writ, called a writ _De coronatore
eligendo_, directed to the Sheriff.
This statute does not define the precise number which varies in different
counties, according to usuage. In some there is only one—in others,
there are two, four, and six coroners appointed. But as no number is
limited by the statute, it is competent for the Lord Chancellor if he
thinks fit, to issue a writ for the election of one or more additional
coroners, upon the petition of the freeholders of a county, and the
approbation of the justices, certified at the general quarter sessions of
the peace, holden for the county.
The degree of knighthood, observes “Sewell on the Law of Coroners,” is
now no longer an essential qualification for the office of coroner. Yet
candidates for that office must it is said, have land sufficient to take
upon themselves that degree, whether they be really knighted or not.
They must be possessed of an estate in fee, within the county, over
which, if elected, their jurisdiction will extend. The statute 14 Edward
3, s. 1 c. 8, enacts, “that no coroner be chosen, unless he have land in
fee sufficient in the same county whereof he may answer to all manner of
people.” No precise amount of estate is defined by this statute, but the
coroner ought to have sufficient property to maintain the dignity of his
office, and to answer any fine that may be set upon him for his
behaviour. But if having an estate in fee within the county, it be
insufficient to answer his fines, that will not operate as a
disqualification or be a ground for his removal, if he be of sufficient
estate to execute his office, for the county, upon his default, will be
liable to the fine as punishment for having elected an insufficient
officer.
The authority of the coroner is twofold:—
1. Judicial
2. Ministerial
In his judicial capacity, he has to enquire when any one comes to his
death suddenly or violently; how and by what means such death was caused;
to pronounce judgement upon out-lawries; to inquire of lands and goods,
and escapes of murderers, treasure trove, wreck of the sea, deodands, &c.
Before the statute of Magna Charta, c. 17, (4,) coroners held pleas of
the crown, but that power is taken away by a more recent enactment. The
Sheriff in his tourne might by the common law, inquire of all felonies,
save the death of a man, but it is doubtful whether the coroner can
inquire of any felony but the death of a person, and that _super visum
corporis_, except in Northumberland, where the coroner may, by custom,
inquire of other felonies.
In his ministerial capacity, he has to execute the King’s writs, when the
Sheriff is a party to the suit, or kin to either of the parties, or on
default of the Sheriff, but they are only authorized so to act in the
execution of a process directed to them when their acts are void, unless
they all join.
Coroners are conservators of the King’s peace, and become magistrates by
virtue of their election and appointment. This privilege, independently
of their more official duties, they are entitled at this day to exercise;
and are empowered to cause felons to be apprehended, as well as those
that have been found guilty after inquisition, as those suspected of
guilt, or present at the death, and not guilty; as also burglers and
robbers, in respect of whom, no inquisition can be taken. And this, says
Lord Hale, appears evidently by the statutes, 3 Edward I, c. 94, and 4
Edward I. _Officium Coronatoris_, and with this agrees the common usage
at this day; for many times the inquest are long in the inquiry, and the
offender may escape, if the coroner stay until the inquisition is
delivered up.
Where coroners are empowered to act as judges, as in taking an
inquisition of death, the act of one of them is of the same force as if
they had all joined.
The office of Coroner being by election, does not determine by the demise
of the king.
The jurisdiction of coroners is limited to the county, liberty, or
precinct, to and for which they are elected and appointed, and cannot be
enlarged by any private act or delegation from the crown.
By the common law, if a man had been stricken in one county, and died in
another, it was doubtful whether he were indictable or liable in either;
but the more common opinion was, that he might be indicted where the
stroke was given. And if the party died in another county, the body was
removed into the county where the stroke was given, for the coroner to
take an inquisition _semper visum corporis_.
But the statute 2 and 3 Edward the Sixth, cap. 24, sec. 2, provided that
when any person shall be feloniously stricten or poisoned in one county,
and die of the same stroke, or poisoning in another county, an indictment
thereof found by jurors of the county where the death shall happen,
whether before the coroner upon the sight of such dead body, or before
the Justices of the Peace, or other Justices or Commissioners, which
shall have authority to inquire of such offences, shall be as good and
effectual in the law, as if the stroke and poisoning had been committed
and done in the same county where the party shall die, or where such
indictment shall be founded. This statute, however, assumed the
existence of a _felony_, and was silent entirely as to what is to be done
by the coroner or jury if no such indictment were found. The effect of
any other finding was left entirely as it stood at common law.
It was thought, too, that the statute 2nd and 3rd Edward the Sixth, cap.
24, did not extend to boroughs; but that in cases of felonious killing,
where the stroke, occurred out of the borough, and the death, within, the
jurisdiction of the coroner, was according to common law.
By the 9th George the Fourth, cap. 31, sec. 8, it was enacted, that,
“where any person being feloniously stricken, poisoned, or otherwise hurt
upon the sea, or at any place out of England, should die of such stroke,
poisoning, or hurt in England, or being feloniously stricken, poisoned or
otherwise hurt at any place in England, should die of such stroke,
poisoning, or hurt upon the sea, or at any place out of England, every
offence committed in respect of any such case, whether the same amounted
to the offence of murder or of manslaughter, or of being accessory before
the fact to murder, or after the fact to murder or manslaughter might be
dealt with, enquired of, tried, determined, or punished in the county or
place in England, in which such death, stroke, poisoning, or hurt should
happen, in the same manner, in all respects, as if such offence had been
wholly committed in that county or place.”
By the 7th George the Fourth, cap. 64, sec. 12, it was enacted, “where a
felony or misdemeanour is committed on the boundary of two or more
counties, or within the distance of 500 yards of the boundary, or is
begun in one county and completed in another, every such felony, &c. may
be dealt with, inquired of, tried, determined, and punished in any of the
said counties, in the same manner as if it had been wholly committed
therein.” This enactment extends to the boundaries of counties only, and
not to prosecutions in limited jurisdictions.
Many difficulties, however, having arisen on the construction of these
statutes, as to the jurisdiction of coroner; by the 6 Vic. cap. 12, it
was enacted, “That the coroner only within whose jurisdiction the body of
any person upon whose death an inquest ought to be holden, shall be lying
dead, shall hold the inquest, notwithstanding that the cause of death did
not arise within the jurisdiction of such coroner; and in case of any
body found dead in the sea, or any creek, river, or navigable canal
within the flowing of the sea, where there shall be no deputy coroner for
the jurisdiction of the Admiralty of England, the inquest shall be holden
only by the coroner having jurisdiction in the place where the body shall
be first brought to land.” And by sec. 2, it is further enacted, “That
for the purpose of holding coroners’ inquests, every detached part of a
county, riding, or division, shall be deemed to be within that county,
riding or division, by which it is wholly surrounded, or where it is
partly surrounded by two or more counties, ridings, or divisions, within
that one with which it has the longest common boundary.” Sec. 3 provides
for the trial of parties on verdicts of murder and manslaughter. Sec. 4,
provides for the levying of deodands on verdicts.
The enquiry of the coroner must be restricted to the cause of the death
of the person upon whom the inquest is taken, and cannot be extended to
accessories after the fact. He may, however, inquire of accessories
before the fact, for such are instrumental to the death. {17}
And by the statute 7 George the Fourth, c. 64, sec. 9, “the offence of
the person counselling, procuring, or commanding, howsoever indicted, may
be inquired of, tried, determined, and punished by any court which shall
have jurisdiction to try the principal felon, in the same manner as if
such offence had been committed at the same place as the principal
felony, although such offence may have been committed either on the high
seas, or at any place on land, within his majesty’s dominions or without.
And in case the principal felony shall have been committed within the
body of any county, and the offence of counselling, procuring, or
commanding shall have been committed within the body of any other county,
the last-mentioned offence may be inquired of, tried, determined and
punished in either of such counties.”
This cursory glance of the office, the election, the authority, and the
jurisdiction of coroners, show at once the importance of the trust
imposed in them. Yet in the present day negligence and laxity prevail to
such an extent, that a coroner’s tribunal is considered an inferior
instead of a superior court, for some magistrates though differently
elected, endeavour to control their labours, on the plea of economy—and
this may be considered as one cause why coroners’ inquests appear
unsatisfactory tribunals, for surely the doing so, must interfere with
the sacred duties imposed and intended to operate on the minds of the
many, that an untimely end of a fellow creature with all the awfulness
attending it, should be carefully inquired into as the safety valve by
which we live and move, and have our being.
The incomparable Dickens has, in one of the numbers of his present novel,
“Bleak House,” sketched a lively representation of the manner in which
these courts are commonly conducted; and as fiction demonstrates
truthfully, truth itself, it may not be considered an unpardonable
liberty in introducing the following extract:
The coroner frequents more public houses than any man alive. The
smell of sawdust, beer, tobacco smoke and spirits, is inseparable in
his vocation from death in its most awful shapes. He is conducted by
the beadle and the landlord to the Harmonic Meeting room, where he
puts his hat on the piano, and takes a Windsor chair at the head of a
long table, formed of several short tables put together, and
ornamented with glutinous rings in endless involutions, made by pots
and glasses. As many of the jury as can crowd together at the table
sit there. The rest get among the spittoons and pipes, or bear
against the piano. Over the coroner’s head is a small iron garland,
the pendant handle of a bell, which rather gives the Majesty of the
Court, the appearance of going to be hanged presently.
Call over and swear the jury!
“Well gentlemen,” the Coroner begins:—
“Silence there will you,” says the beadle—not the coroner, though it
might appear so. “Well gentlemen!” resumed the coroner, “you are
impanelled here, to enquire into the death of a certain man.
Evidence will be given before you, as to the circumstances attending
that death, and you will give your verdict according to the evidence
and not according to anything else. The first thing to be done is to
view the body.
“Make way there!” cries the beadle.
So they go out in loose procession, something after the manner of a
straggling funeral, and make inspection, from which a few of the
jurymen retire pale and precipitately.
The inquiry proceeds. The jury learn how the subject of the inquiry
died, and learn no more about him. “A very eminent solicitor is in
attendance, gentlemen,” says the coroner, “who I am informed was
accidentally present, when discovery of the death was made; but he
could only repeat the evidence you have already heard from the
surgeon, the landlord, &c., and it is not necessary to trouble him.”
Is any body in attendance who knows anything more?
Mrs. Piper pushed forward by Mrs. Perkins.
Mrs. Piper sworn.
Anastasia Piper, gentlemen, married woman.
Now, Mrs. Piper—what have you got to say about this?
Why Mrs. Piper has got a good deal to say, chiefly in parenthesis and
without punctuation, but not much to tell. Mrs. Piper lives in the
court, (which her husband is a cabinet maker,) and it has long been
well be known among the neighbours (counting from the day next but
one before the half-baptising of Alexander James Piper, aged eighteen
months and four days old, on account of not being expected to live,
such was the suffering of that child, gentlemen, in his genus) as the
Plaintive—so Mrs. Piper insists calling the deceased—was reported to
have sold himself. Thinks it was the Plaintive’s air in which that
report originatin. See the Plaintive often, and considered his air
was fearinocious, and not being allowed to go about, some children
being timid, (and if doubted, hoping Mrs. Perkins may be brought
forard, for she is here and will do credit to her husband, and
herself and family.) Has seen the Plaintive wexed and worrited by
the children, (for children they will ever be, and you cannot expect
them, specially if of playful dispositions to be Methoozellers which
you was not yourself.) On accounts of this and his dark looks, has
often dreamed as she see him take a pickaxe from his pocket and split
Johnny’s head, (which the child knows not fear, and has repetually
called after him close at his eels). Never however, see the
Plaintive take a pickaxe or any wepping far from it. Has seen him
hurry away when run or called after, as if not partial to children,
and never see him speak to neither child or grown up person at any
time, (except the boy that sweeps the crossing down the lane over the
way round the corner, which if he was here, would tell you that he
has been seen a speaking to him frequent.) Says the coroner, is that
boy here? Says the beadle no, sir, he is not here. Says the
coroner, go and fetch him then.
Oh! Here’s the boy, gentlemen!
Here he is, very muddy, very hoarse, very ragged. Now boy!
But stop a minute. Caution. This boy must be put through a few
preliminary paces.
Name, Jo. Nothing else that be knows on. Don’t know that everybody
has two names. Never heerd of sich a think. Don’t know that Jo is
short for a longer name. Thinks it long enough for _him_. _He_
don’t find no fault with it. No lather, no mother, no friends.
Never been to school. What’s home? Knows a broom’s a broom, and
knows its wicked to tell a lie. Don’t recollect who told him about
the broom, or about the lie, but he knows both. Can’t exactly say
what’ll be done to him arter he’s dead if he tells a lie to the
gentlemen here, but believes it’ll be something wery bad to punish
him, and serve him right—and so he’ll tell the truth.
“This won’t do, gentlemen” says the coroner, with a melancholy shake
of the head.
“Don’t you think you can receive his evidence, sir,” asks an
attentive juryman.
“Out of the question,” says the coroner, “you have heard the boy.”
‘Can’t exactly say’ won’t do you know. We can’t take _that_ in a
Court of Justice, gentlemen. It’s terrible depravity. Put the boy
aside.
Now. Is there any other witness? No other witness.
Very well, gentlemen! Here a man unknown proved to have been in the
habit of taking opium in large quantities for a year and a half,
found dead of two much opium. If you think you have any evidence to
lead you to the conclusion that he committed suicide, you will come
to that conclusion. If you think it is a case of accidental death,
you will find a verdict accordingly.
Verdict accordingly. Accidental death. No doubt. Gentlemen, you
are discharged. Good afternoon.
While the coroner buttons his great coat, the eminent solicitor, and
himself, give private audience to the rejected witness in a corner.
That graceless creature only knows, that the dead man (whom he
recognised just now by his yellow face and black hair) was sometimes
hooted and pursued about the streets. That one cold winter night,
when he, the boy, was shivering in a door-way near his crossing, the
man turned to look at him, and came back, and, having questioned and
found that he had not a friend in the world, said, “Neither have
I—not one!” and gave him the price of a supper and night’s lodging.
That the man had often spoken to him since; and asked him whether he
slept sound at night, and how he bore cold and hunger, and whether he
ever wished to die, and similar strange questions. That when the man
had no money, he would say in passing, “I’m am as poor as you to-day,
Jo,” but that when he had any, he had always (as the boy most
heartily believes) been glad to give him some.
“He was very good to me,” says the boy, wiping his eyes with his
wretched sleeve. “Wen I see him a layin so stritched out just now, I
wished he could have heard me tell him so. He was very good to me,
he was!”
It may be asked, is the above an over-drawn picture of what is frequently
observable in coroners’ courts? If answered in the negative! surely the
time has come for the reception of additional evidence, with the view,
not only to improvement in accordance with the age in which we live, but
for the maintenance of the legitimate object for which coroners’ courts
were first established, and which they profess to uphold in all the
integrity of seeking _the truth_, _the whole truth_, _and nothing but the
truth_. Under these circumstances it becomes an imperative duty to
record cases where discrepancies exist or have existed.
Case 1.—In the village of R—, a few years since, a young woman denying
her guilt to the latest moment, was one morning discovered by her
relatives entering her bed room, apparently in a dying state. Observing
the clothes saturated with blood, they sent for a medical gentlemen, who
immediately attended, and soon ascertained that the cause of the
hemorrhage arose from her having been recently confined. On accusing her
of the fact and enquiring where she had put the child—with quivering lip
and trembling hand, she pointed to the opposite side of the bed, beneath
which, was a box, containing the body of a full-grown infant. Externally
it appeared perfectly healthy, but the face was dark and tumid,
especially the lower part and around the neck, a mark, as if a cord had
been tightly held or fastened, was distinctly visible. At the coroner’s
inquest held shortly after, the medical attendant deposed, that
collateral evidence proved the child was born alive, and the mark alluded
to, corroborated his opinion that the child had been strangled. On this
evidence, and this evidence alone, as no cord, tape or missile could be
found, the jury, at the coroner’s suggestion, returned a verdict of
“wilful murder.” At the following Assizes, in Norwich, the judge who
tried the culprit, elicited from the medical gentleman, that it was
possible for the child to be strangled in its birth from natural
causes—that the cord or funis belonging to the child, itself might
surround the neck, and by impeding its birth, produce strangulation and
death. Under the direction of the judge, the jury immediately returned a
verdict of “not guilty,” and the prisoner returned home to her friends,
who rejoiced in her acquittal, and believed her an injured person.
Had the coroner at the inquest ascertained the above fact, she would not
have been committed to be tried for murder under his warrant, but for
misdemeanour, concealing the birth of her child. Thus she narrowly and
properly escaped the punishment for the capital offence, but improperly
escaped the punishment which would have been awarded her by the offended
laws of her country, for conduct she richly merited and deserved.
Case 2. The wife of an agricultural labourer, in the parish of I— was in
the habit of going to work in the fields, and leaving her children
without fire or food from morning till night, and if on her return she
found them crying or murmuring, she would flog and send them to bed
supperless. One of the poor children was attacked by the measles, and
although the eruption had partially made its appearance, she carried it
to the field where she worked, laid the child under a fence, as it was
too ill to sit up, and there it continued the whole day, part of the time
exposed to a fog off the German ocean, which rendered the surrounding
atmosphere cold, moist and insalubrious. Returning homewards in the
evening with her child, she observed it was getting worse, and two or
three hours after, she asked a neighbour to come and see it, which she
did, and advised the mother to send immediately for the parish surgeon.
He promptly attended, but gave no hopes for its long surviving, as it was
labouring under acute inflammation of the lungs, and in a few hours after
his opinion was verified, for the child expired. Some days elapsed
before an inquest was held over the deceased. The parish surgeon deposed
the child died from inflammation of the lungs, following the measles. On
being asked whether he did not think death was accelerated, owing to the
child being exposed to cold, he said “No! on the contrary, I consider it
beneficial.” In this instance, the medical gentleman was requested by
the coroner to re-consider his statement, as he had always understood by
checking such eruptions, they were liable to be fatal—but the parish
surgeon would not retract, and the coroner rested satisfied, by merely
reprimanding and cautioning the woman to take better care of her
children.
Thus was inhumanity shielded in its career; as if the life of a child
might be sacrificed with impunity.
Case 3. The daughter of a respectable tradesman, in the parish of
I—unknown to a part of her family, gave birth to an infant. At four
months old, she introduced it for a short time amongst them, as belonging
to somebody else. When about to leave home, she engaged another woman to
carry it part of the road she was going, promising she would soon
overtake her. On reaching the village of L—, a distance of four miles
from whence she started, the woman looked at the infant attentively, and
thought it was dying. Being alarmed, she entered the first public house
she came to, imparted her suspicions, and on close examination, found her
fear was not groundless, for the infant had ceased to exist. A coroner’s
inquest was summoned, and evidence given that the parent had expressed
other than a mother’s fondness for her child. Laudanum had been
purchased the night previously, from a shopkeeper in the village by her
order, and on receiving it, she tore off the label which denoted the
deadly poison, and the phial was subsequently found emptied of its
contents. Here apparently a link in the chain of evidence was broken.
Two medical gentlemen who made a post mortem examination of the body,
deposed that laudanum had been administered to the child, but they were
not prepared to say in sufficient quantity to cause death. {28}
A verdict under the coroner’s direction, was recorded that the child died
by the visitation of God; but material evidence from other witnesses was
withheld, which might have unveiled the mystery surrounding the death of
the innocent, and the strongly suspected parties might have been brought
to justice.
It is generally known, sooner or later, to habitual drunkards, that too
much indulgence in strong beverages, particularly spirituous liquours, is
followed by becoming more and more susceptible to their intoxicating
effects, although partaken of in smaller quantities. This is owing to
established facts; the liver becomes diseased, the nervous system becomes
shattered, the brain itself participates in the mischief, so that reason
losing its sway in the earlier period becomes permanently injured, and
either madness or imbecility; premature age, or organic disease are the
inevitable consequences. From the cradle to the grave, a predisposition
to decay exists in every one which would far more frequently lie latent,
until Old Mortality could no longer stay, did not this, the most
disgraceful of all-exciting causes, thus step in and cut the thread of
life when least expected, and probably least prepared.
Such was the case with a schoolmaster, who when living, resided in the
village of H—. He prematurely suffered from Idiopathic irritation of the
bladder, for on carefully sounding him, no stone could be detected, and
therefore it was conceived, that inflammatory action in that viscus
existed, which accompanied with pain at intervals, especially during the
night annoyed him exceedingly. Disease advancing, he consulted a general
practitioner in the neighbourhood, and subsequently other medical men,
among them an eminent physician in Norwich. But the obstinacy of the
disease soon caused his confidence to be shaken, and fearing the result,
he yielded to the foolish solicitation of meddling acquaintance, who
persuaded him to consult a notorious quack. Complying with their wish,
he followed the advice given by the remorseless pretender to knowledge in
disease, and applied bullock’s milts to the feet, partook of stimulants
(ammonia and spirits of turpentine) in the day, with brandy and laudanum
at night; on taking only two doses of the former, his anguish increased
considerably, which became partially allayed by the laudanum, but no
sleep succeeded—the expression “the complaint has flown upwards,” escaped
the lips of the dying man, and delirium closed the scene.
To consult the accelerator of his death—the iniquitous quack—he undertook
a journey of forty miles, only four days previously; and although the
disease might eventually have killed him, still his condition was good,
emaciation had made but little progress, and his appetite continued
excellent. From taking stimulants, the gradual decay of nature was
denied him. His agony was such, that in cases like his, an Infinite and
Merciful Being has wisely ordained that collapse should take place, that
the nervous system should receive a lasting shock, and thus was the
schoolmaster the victim of credulity, relieved of his earthly pilgrimage.
Such a sudden termination in the death of this unfortunate being
naturally aroused the attention of the neighbours. A coroner’s inquest
was summoned, and the gentleman in office proceeded to his duty; but the
cause of death not being ascertained to the mutual understanding of
himself and jury, an adjournment took place. In this instance, though
informed that a general practitioner in the neighbourhood attended the
schoolmaster in the earlier period of his illness, yet the coroner
neglected to call him as evidence, but observed to the jury he should
take the phials left in the possession of the friends of the deceased, to
have the contents analyzed. Returning homewards, he called on a medical
gentlemen, stated his mission, and requested he would on a day named,
attend and give evidence. This was assented to, and on the investigation
being resumed, the question put to the witness was “What is the nature of
the disease, and the cause of death?” he replied, “He could not tell, as
he had not been consulted by the deceased during his illness, but he
believed the medicine prescribed was harmless—would neither kill nor
cure—although he did not approve of the treatment.”
Here the coroner rested satisfied with this superficial enquiry in search
of truth, and addressing a readily assenting jury, advised a verdict
should be recorded that the deceased died by the “Visitation of God;” and
thus was suffered to escape, one of the finest opportunities to expose
and punish the unpardonable vanity of a dabbler in physic, who openly,
yet certainly, disclosed the fact that he and his fraternity are allowed
to deprive with impunity the lives of the weak minded, the most to be
pitied among Her Majesty’s subjects.
Case 5. The last example necessary to quote at present, more recently
occurred in a village in the county of Norfolk, which requires peculiar
notice and consideration, owing to the respectability of persons
connected with the affair.
Reports of an extraordinary character had been in circulation several
weeks before the event transpired; and this enquiry actually rested on
what is termed in medical language Mala Praxis. {32}
A poor agricultural labourer, William Swann, came to an untimely end,
through circumstances of an aggravated character, leaving a widow and
nine children to deplore his irreparable loss; for among this, the
humblest classes of society, there are ties of affection naturally
entwined by which they are endeared to each other, more than is
frequently observable among grades of a similar character in towns or
cities. From their means being limited, their fare less sumptuous, their
sayings and doings more immediately exposed, and their abodes being apart
from the habits, bustle, and temptations existing in more populous
neighbourhoods, are satisfactory reasons for the truth of the above
assertion.
The unfortunate deceased observed his health giving way in the month of
August last year, and he consulted the parish surgeon, Mr. John Coleby,
who found him labouring under irritation of the left kidney, produced by
the detention of gravel, which lodging there, pained him exceedingly.
The treatment suggested, was attended with various results, sometimes he
was relieved for a few days, then he relapsed, and after several weeks
illness, a small stone escaped into the bladder.
Swann’s health, however continuing impaired, his wife replied to various
inquiries, “he was no better,” and having remarked that she considered
the parish surgeon inattentive, a warm-hearted lady, (Mrs. Shirley)
expressed a wish that the poor man should consult her medical man, Dr.
Bell, residing in Norwich, in whose skill and medicine she had great
confidence. Swann consented—was placed by Dr. Bell, on his arrival in
Norwich, under the care of Mrs. Phillips’, and the testimony of the
different witnesses at the inquest, afterwards held on the body of the
deceased, proclaims the result.
The evidence first called, was Mrs. Swann, the widow of the deceased, who
stated “My husband was 45 years of age. In the early part of last
harvest he was very ill, and he applied to the parish doctor, Mr. Coleby,
who attended him until after Christmas, and I told Mrs. Shirley, I did
not think Mr. Coleby did justice to him, so she sent him to Norwich to be
under her medical man, Dr. Bell. He went on Wednesday, the 11th of
February, in a carrier’s cart, and took lodgings of a Mrs. Phillips, in
Union Place. He told me that Dr. Bell attended him the same day, that he
went up and passed five instruments into his body. He said that Dr. Bell
hurt him very much and he (Dr. Bell) passed his instrument up further,
which caused a large stream of blood to come from him. Dr. Bell gave him
some medicine and continued to attend him a fortnight, when he said he
would not take any more. On hearing him say so, Dr. Bell asked him who
he would have come to him, he said Mr. Webber, as he was with him when
Dr. Bell passed the instruments. Dr. Bell wrote to Mr. Webber to attend,
but he would not; I went to Norwich that day, and by my husband’s desire
I called on Mr. Webber, and asked him to come and see him; he came and
examined him, and said inflammation had taken place, but he would do his
best endeavours for him. Mr. Webber attended him five weeks, and he came
home on the 30th of March last. Mr. Coleby attended him the next day,
and continued to attend him until he died, on Friday, the 14th of May—he
frequently complained of his kidneys.”
The next evidence was Margaret Phillips, an experienced nurse, who stated
“Her lodgings and services were engaged by Dr. Bell, and that the
deceased was placed under her care, on the 11th of February—she was
present when Dr. Bell sounded him for stone, which was done in the
presence of Mr. Webber. The instruments he used with considerable force,
but he could not succeed in passing them. The poor man suffered very
much, which no doubt induced Mr. Webber to call out “That’s not my way of
sounding, let me try.” But Dr. Bell refused. He jumped up and getting
another sound, attempted to pass it with no better success. I called out
“Dr. Bell, the instrument is cold, for God’s sake have some hot water,
and oil it well,” for previously he had only oiled it slightly. He took
my advice, he used another instrument, and applying considerable force,
he passed it through, and during the time the patient suddenly called out
“I feel it go through somewhere, it hurts me dreadfully.” After this,
Dr. Bell said to Mr. Webber “do you try,” which Mir; Webber did, but
observing “I prefer my own sound,” which he, without difficulty,
immediately passed. I saw some blood escape, not much, immediately after
Dr. Bell withdrew his instrument.
“Shortly after the deceased went out to see about his linen which was
left at the public house where the conveyance stopped, that had brought
him to Norwich. This was a short distance from my house, and soon
returning, the deceased observed that he was in dreadful pain, had been
losing a deal of blood, and on calling for a vessel, the blood came from
him in a stream. He continued to bleed some time, and becoming alarmed,
I called upon Dr. Bell to come to Swann’s assistance. He quickly
attended, and soon after the bleeding ceased. From that time the
deceased continued to be a great sufferer, and on Dr. Bell visiting him
_three_ days after, I said to him privately, I am sure you have injured
that poor man, I never saw a man lose so much blood before from sounding,
nor yet complain of so much suffering. Dr. Bell inquired of the deceased
“whether it was Mr. Webber or him that hurt him,” he said “you, sir!”
Dr. Bell then asked “are you sure it was not the other gentleman,” the
deceased said “No—it was you, I did not feel Mr. Webber’s instrument
pass, he gave me no pain.” Dr. Bell continued to attend him a fortnight
or three weeks, she could not recollect which. No other medical man
attended during this time, but the poor man getting worse and worse, Dr.
Bell brought Mr. Webber again to see him. They did not agree as to their
treatment of him, Mr. Webber suggested one course, but Dr. Bell refused
to do so. They left my house, and I do not know what passed, but Dr.
Bell shortly after returned, and said “Nurse, at your peril you are not
to suffer any medical man to interfere, he is not to take any thing
except from me, as Mrs. Shirley said he was to be entirely under my
care.” I said “of course Dr. Bell I do not want to bring any medical man
in, the only gentleman that has been, you brought yourself.” The
deceased had no other medical man at that time to attend him; he
continued to get worse, and I was obliged to call up Dr. Bell one night,
and then he was very much frightened, and asked “What can be the cause of
all this?” I said, “The cause is what Mr. Webber told you would be the
result—ulceration,” and I exclaimed “Oh! good God, what will become of
the poor woman and children?” he replied, “Mrs. Shirley will take care of
them.” I begged and prayed of him not to go out of the way and leave me
with a dying man without doing something himself, or sending another
medical man; he then went up-stairs to Swann, and asked him again whether
he would take his medicine, and the man said “No—no more,” I heard him
say so. When Dr. Bell came down stairs again, he asked “Who can have set
this man against my medicine?” I said, “Go up-stairs and ask him in the
presence of witnesses”—Dr. Bell did so, and said, “My good man, who set
you against me and my medicine?” He replied, “No one but the pain the
medicine gave me.” Dr. Bell then left the house and ceased attending
him, and Mr. Webber was called in. He ordered the deceased some
medicine, and fomentations to allay pain, which were continued several
days. He called in Mr. Gibson to witness the condition of the patient,
for he was afraid the man would die in the state he was then in, and they
talked about medicine and treatment. Mr. Gibson called once more, and
said “the man was in good hands.”
“The deceased came to my house on the 11th of February, and left me
exactly seven weeks after. Dr. Bell called on me at the end of six
weeks, and said that “Mrs. Shirley insisted on the man being sent home,
and that I should not be paid more than six weeks lodging.” I said, “I
could not send him home on my own account; but that Mr. Webber would send
him home when he thought fit.” Mr. Crickmay, another surgeon had also
seen Swann several times, with Mr. Webber, and that he had nothing
further to suggest.”
Mr. John Coleby deposed, “I am a surgeon, residing at North Walsham, and
I was summoned to attend the deceased last August; he complained of pain
across the loins, particular in the region of the left kidney, and I
treated him accordingly. After some time I suspected a stone had escaped
into the bladder, I passed an instrument twice without any difficulty, in
November, the first time without success, but the second time I detected
a small stone. At that time his health was so indifferent, as to lead me
to believe had I operated upon him, his life would have been the
sacrifice. I then prescribed such medicine as I thought conducive to his
benefit, with a view to prepare him for the operation, and I remarked to
him previous to his going to Norwich—put yourself under my care, you have
a stone in your bladder, but I cannot advise you to be operated upon
immediately. He however went to Norwich, and I called upon the deceased
whilst he was lodging at Mrs. Phillips’. I never saw a man so much
altered as he was in so short a time, which I consider to have entirely
arisen from the bad treatment he had received—I really thought he would
die. Mr. Webber had previously opened an abscess, which had formed in
the central lobe of the testis and pus {39} was escaping. On the 30th of
March last, he returned to Knapton, and I called to see him the following
day, I found him in a very debilitated and exhausted state. He was then
labouring under irritation of the bladder, accompanied with an
inflammatory affection of the left kidney. He continued to linger nearly
six weeks, suffering great agony to the last, and on the 15th of May, I
performed a post mortem examination on the body of the deceased, in the
presence of Mr. Webber and Mr. Crickmay, of Norwich; Mr. Evans, of
Coltishall; his assistant, Mr. Tibbetts, and my own assistant, Mr.
Cheverton. I examined the left kidney, which was considerably enlarged,
and in the renal capsule connected with the ureter, there had evidently
been inflammation, for an abscess had formed there, which caused his
death. I have no ill feeling towards any one in stating it to be my firm
opinion, that this abscess, like all the others in his case, resulted
from the violence used by Dr. Bell, in passing the instrument, and that
which hastened his death. Since the man returned home, he told me
frequently ‘he owed his death to Dr. Bell.’”
Here the coroner, turning to the jury, observed, “The deceased died from
natural causes, shown in the evidence of Mr. Coleby, for his death was
owing to an abscess in the _renal_ capsule of the kidney, and that is
sufficient.”
Dr. Bell, who had been sitting next the coroner, in a juxta position with
one of the jury, with whom he was observed to be often earnestly talking,
then rose, and said “He could not leave that room without offering a
defence for the sake of his family and friends, as he perceived that his
character was at stake, and in spite of the remonstrance used by Mr.
Webber. Dr. Bell obtained the sanction of the court, and was proceeding
to state, that he was M.D. surgeon, when Mr. Webber objected such was not
evidence, that the coroner was at liberty to call Wm. Bell, of Norwich,
but that this witness must state his qualification on oath. He was then
formally sworn, and stated, “I am a surgeon M.D. at Norwich. The man was
sent to me from Knapton, by Mrs. Shirley, (whose letter the witness
read.) The man reported to me that he had been ill on the previous
harvest—that he had been attended by Mr. Coleby daily, and that he had
been under his treatment until he visited me on the morning of the 11th
of February. His symptoms led me to ask him if Mr. Coleby had ever
examined his bladder, naturally suspecting that he was labouring under
stone. He said that Mr. Coleby had done so, and told him that there was
no stone. That for months he had passed blood, and on some occasions
something remained at the bottom of the vessel he used, if allowed to
stand. He appeared to be extremely weak and emaciated. I took him to my
house where I examined him with a sound, and immediately detected a small
stone. I then wrote to Mrs. Shirley, of which I have kept a copy, but
that lady has lost the original. Dr. Bell then read a note in which was
stated that he had examined the man, who was in a deplorable state. That
he had a small stone in his bladder, and had evidently been under a
dangerous affection since last harvest—she could adopt one of three
courses—_she could place him under the care of Mr. Coleby again_, _and
when his attention was more immediately directed to the case_, _perhaps
he would be more fortunate in detecting the nature of the complaint_—or
she could send him to the Norfolk and Norwich Hospital—or she could place
Swann under his care, and he should be happy to attend without any
charge, and the only expense would be for his board and lodging.
Whatever plan should be adopted, let it be with the sanction of Mr.
Coleby, and if he found relief from that gentleman, he was not to be
taken from him, but strictly to attend to his (Dr. Bell’s) directions pro
tempore. He also read a note from Mrs. Shirley, wherein she sanctioned
Swann being under his care.
“The man returned home that day, and remained a week when he came again
to me. I called upon Mr. Webber and mentioned the ease of the poor man
who had been to me, and handed to him the two notes I received from Mrs.
Shirley on the subject. Mr. Webber said he was exceedingly anxious to
see the practice of Homæopathy, and if my remedies failed in removing the
stone, he would be very glad to operate on the man, if I would allow him.
Accordingly on the morning of the man’s arrival to stop in Norwich, which
was Wednesday, the 11th February, Mr. Webber accompanied me to his
(Swann’s) lodgings, at Nurse Phillips’. We sent the man up to his room,
and desired him to prepare himself—Mr. Webber, myself, and the Nurse
followed soon after. I then attempted to introduce my sound into the
man’s bladder—the one I had used before; on this occasion I found the
instrument from being cold, seemed to be grasped by the uretha; I ordered
the nurse to bring some warm water, with which I warmed another
instrument and passed it through. Upon Mr. Webber calling the attention
of the jury to this expression, Dr. Bell said ‘I introduced it with the
greatest facility.’ I immediately felt a stone, and I then passed the
instrument to Mr. Webber, who said he felt it also. He withdrew the
instrument, and upon my solemn oath, not a particle of blood or sign of
blood followed. After the lapse of a minute or two, Mr. Webber drew an
instrument of a large size from his pocket and introduced it, and he also
injected some hot water. (Mr. Webber here exclaimed ‘hot water.’) On my
oath, gentlemen, not hot water, but scalding water. Directly after this
instrument was withdrawn, the man left the house. On my next visit, it
was reported to me by the man and the nurse, that he had been parting
with a good deal of blood, and I prescribed accordingly—I never
introduced any instrument after that. Every visit that I made
afterwards, I found that the man became more and more dissatisfied—he
said he was anxious to leave me and Mr. Webber and go home, and the nurse
declared that Mr. Webber had injured the man by the injection. Finding
that he did not improve—that his nervous system was becoming more
irritable, I called on Mr. Webber the following Wednesday morning, who
observed I had done evil in bringing the man to that woman’s house, and
we went and visited him.
“The days on which Mr. Webber saw him with me, were the 11th, the 18th,
and the last time, the 22nd of February. On these occasions, Mr. Webber
spoke to me respecting my treatment, and that was the reason why the
man’s confidence in me was removed—but this was not all—on the evening of
Sunday, the 22nd, Mr. Webber visited the man when I was not with him;
after doing so, he sent me a note, and here it is:—
Dear Sir,
Having since I parted from you, been again summoned to the
neighbourhood of Crook’s Place, I took the opportunity of giving
Swann another look, I saw no ground for altering the opinion I openly
expressed to you at our meeting; nor will I suffer the real issue in
the case, the security and welfare of the patient, to be prejudiced
by irreconcileable and strange disclosures which have been made,
reflecting most unfairly and ungenerously upon me, considering the
candour and frankness I have shown towards you, but to which I shall
not now further allude, the real object of this note, being in my
estimation of far more importance than professional differences;
therefore, let me again beg of you to lose no further time in
pursuing those measures, of which you at our first meeting expressed
yourself as “sceptical or doubtful,” but at once to adopt more
energetic means for the relief of the sufferer.
Understand me, I do not mean for a moment to assert that the
inflammation which you agreed existed, may not abate or be determined
without the application of the leeches, &c., but surely the known
sequelœ of neglected opportunity, such as ulceration, &c. ought to be
thought of, and if possible, to be averted—they being as effects
quite as mischievous in the end, as the cause—the inflammation
itself; the only difference that I ever observed, being that the one
destroys quicker than the other, but both as certainly.
The patient begged of me to write to Mrs. Shirley, and state the
facts of the case, and I cannot deny his request; but I will “nothing
extenuate or aught set down in malice.”
As you have admitted to me, that you occasionally give half-grain
doses of opium and of quinine (allopathic doses,) as “homæopathic to
disease” (?) excuse my ignorance, you will I apprehend, have no
difficulty in carrying out sound constitutional treatment, with local
means, in the case in point.
I am, Sir, yours in much haste,
W. WEBBER.
St. Giles’, Sunday, Feb. 22nd, 1852.
To Dr. Bell.
“This shows that Mr. Webber went in my absence and talked to the man. I
had told him to leave Swann in my hands, but instead of that, he visited
him in my absence. Up to that night, the nurse had invariably told me
that it was the injection which had injured him, but after that, Mr.
Webber and the nurse seemed to have set him against my treatment. On
Tuesday, the 24th, when I visited him, he would have nothing to do either
with me or my medicine, and the nurse suggested that I should send for
another medical man.
“On Wednesday morning, the nurse came to me, and asked me to see him
early. I went immediately to him, and found him labouring under a
paroxysm of the stone. He declined to receive any medicine from me. The
nurse then suggested that Mr. Webber should attend him—I was much
surprised at this, as previously she had always abused Mr. Webber. I
asked the man if he wished Mr. Webber to see him, and he replied that he
did. About nine o’clock the same morning, I wrote to Mr. Webber, stating
that the man refused to use my medicine, and that he wished to see him.
Mr. Webber sent me a note, stating that the wife of Swann had just been,
and requested that he would take charge of her husband’s case, which he
had promised to do. The man after this remained five weeks in Norwich,
during which I had nothing to do with him.”
The coroner commenced ordering strangers and witnesses to withdraw,
previous to his summing up, when Mr. Webber asked the coroner why he had
been summoned, and insisted on his right to be heard, after the palpably
incorrect statements which Dr. Bell had been allowed to make—the coroner
replied that he did not consider it was necessary for Mr. Webber to give
evidence at all. {46} The foreman of the jury, (Mr. Coleman) said “He
thought it would be no more than right, that as Dr. Bell had made a
statement, Mr. Webber should be allowed to make a statement also;” this
opinion his brother jurors coincided in, and much against the inclination
openly expressed, and the significence of great and frequent impatience
of the coroner during the time occupied in the delivery of the evidence.
Mr. Webber, after being sworn, deposed as follows:
I am a M.R.C.S., Eng., residing in Norwich. I received a note from Dr.
Bell on the morning of the 11th of February, who asked at what time I
could see a patient of his who had been sent by a lady, to be placed
under his care, to which I returned an answer, and agreeably to
arrangement, Dr. Bell called on me, and proceeding on our way to Mrs.
Phillips’, in Union Place, he said he believed the patient, Wm. Swann had
a stone in his bladder. That Mr. John Coleby of North Walsham had
examined him, but had not found one, and he therefore wished to be
satisfied that he was correct in the opinion he had formed. That he
intended to treat him homæopathically, and that if the man should not be
relieved by his treatment, about which he was “sceptical,” (“as he had
had no experience in this disease”)—he would then hand him over to me to
be operated upon, as he believed I was fond of operating in such cases—I
told him I had no fondness for cutting up anybody, but, that when
operations came in my way, and they were necessary, I never hesitated to
perform them. He said he was not in the habit himself of operating in
such cases. I agreed to go and examine the case, stating at the same
time that I would have nothing to do with the treatment he proposed.
That if his system proved to be a sound one, I should not hesitate to
proclaim it as a great boon to suffering humanity, but that if it should
prove to be otherwise, he might rest assured I should expose it.
Arriving at Nurse Phillips’, I there saw Swann, who was a man about five
feet, nine or ten inches in height, in tolerably fair plight, no
emaciation, no evidence of extensive organic disease going on, nothing
beyond a slight wearing from the irritation which generally accompanies
stone in the bladder, and with nothing in his appearance to interdict an
operation after a week or two preparation, nor to exclude the benefits of
opportune and proper treatment.
It is usual when a consulting surgeon is called in, to allow him to
perform the manipulation, but in this case Dr. Bell himself passed the
sound—I stood by while he attempted to pass it, which in my opinion was
of a very objectionable form, and such a one as he would be likely to
experience difficulty in introducing, and not calculated to detect the
stone when in. On passing it down to the commencement of membranous
portion of the urethra, he came to the check which I had anticipated; he
then made forcible attempts to pass the instrument, despite my advice not
to do so, conveyed in the words “Oh do not use force; pray do not use
force—force will do no good, you will do harm.” That instrument was
withdrawn, but not until force had been used. Another and smaller
instrument was tried by him, when the nurse suggested that he had better
use some warm water, as she thought the instrument might be cold, and she
brought some. A further attempt was made to pass the instrument, and
more force was applied, and Swann cried out “Oh! sir, you have hurt me,
it has gone somewhere, I think it has gone wrong,” of which, I myself,
entertained no doubt. The instrument was then partially withdrawn, and I
seeing where the difficulty existed, recommended that this sound
(producing it {49}) should be passed instead, for it had never fallen to
my lot to see such unskilful manipulation as was exhibited by Dr. Bell,
whose hand shook considerably at the time. He then turned the instrument
and effected an entrance into the bladder. He said he felt the stone,
and requested me to take the instrument, I did so, and felt a grating,
but not being satisfied, I requested him to withdraw his instrument and I
would introduce mine. I have no doubt that the urethra had been
lacerated, for on his withdrawing his instrument, blood dropped on my
boot. I do not say there was any great quantity, nor was it likely there
would be, because it became extravasated; therefore, I adopted my usual
plan in such cases, which was to introduce an instrument as large as the
passage. I passed the instrument into the bladder and struck the stone,
and I believe the sound was audible to the nurse, who is accustomed to
such cases. Dr. Bell not being satisfied, on this, I withdrew the sound,
and proceeded to inject into the bladder tepid water, as no surgeon in
his senses would do what Dr. Bell states I did—use _hot_ water, and if he
would, he could not, for the patient would not let him. I then handed
the instrument to Dr. Bell and turned the stop cock, allowing water to
run out, so that the stone might fall on the end of it which it did, and
was heard distinctly by those present, and Dr. Bell having assured me he
felt it distinctly, it was withdrawn. During the progress of the
examination, I asked the man whether he felt any serious pain, and he
said, “I hope you have done, for I am getting very faint.” As he was
very deaf, I put the question to him again, and asked him, did the last
instrument hurt you? and he said “No; the last instrument did not hurt
me.” All this was done openly. Dr. Bell said he was going to treat the
man homæopathically; I said “he might do as he pleased, he might humbug
the patient, but that he should not humbug me, and I would have nothing
to do with such treatment.” Dr. Bell then mixed some medicine in some
water in a tumbler glass; it did not readily dissolve, and he called for
another tumbler, and in order to dissolve it, he poured the contents of
one tumbler into another several times, and in the process, spilled one
half of it. Thus showing how important _these medicines_ are in their
_integrity_. It was arranged that if the man was not benefitted at the
end of a month, he should pass into my hands to be operated upon. I
remarked to him that that time would afford no criterion of the value of
his treatment, as patients had what is called fits of the stone, and if
the fit went off, he would take the credit of curing the man, when in
fact he had done no such thing. Dr. Bell states that I saw the man on
Wednesday, the 18th, but that is not correct, as on that day I was called
to and attended a patient in Cambridgeshire. On the following Sunday,
(the 22nd,) he came to me and asked me if I had seen the man again, I
replied certainly not—he asked me if I would come and look at him,
because said he, “my treatment does not appear to succeed with him, I
have no great confidence in its success.” I went with him to nurse
Phillips’, and never in my life did I behold a man so changed—his
condition was that of a man suffering under acute inflammation. I
immediately turned up the bed clothes, or rather the sheet, and placing
my hand lightly on the body, I was about to examine the state of the
bladder, when he shrieked violently, saying “Oh! take away your hand,
sir—I cannot bear it—you will kill me!” I had used no pressure. I then
turned round and said, “Dr. Bell, how comes this about? Why the man has
got inflammation of his bladder, what have you been doing?” The man was
rather deaf, but he caught the last words, and looking at Dr. Bell, said
“you have done it; you have given me poison.” Dr. Bell remarked, “I have
merely given him nux, {52} because his bowels were confined.” I then
said “there is no time to be lost; I fear the man will die; you had
better put on leeches, as soon as you can, and have recourse to
fomentation, and the sooner the better,” when Dr. Bell remarked “Can we
not go some where else and talk?” I said “No, sir, whatever I do every
body is welcome to see and hear, I will be a party to nothing in the
dark, and I will tell you, unless you stop this inflammation soon, it
will soon stop the man.” Dr. Bell said “that he would not take a drop of
blood from the man, and he mentioned the names of several persons who, he
said, _knew_ the cause of inflammation, and that it could be stopped
without it.” Being called into that neighbourhood on the evening of the
same day to attend a patient of my own; and being anxious about the poor
fellow, I called again at Mrs. Phillips’, but did _not_ see the deceased.
The nurse said that she had used fomentation, but the man was in great
pain; I asked if Dr. Bell was there, and on her replying that he was not,
I said I would write to him, (and hence the letter which Dr. Bell has
thought proper to produce in his defence.) I then took my leave—Dr. Bell
continued to attend him, on the Monday and Tuesday, and on the Wednesday,
I received a note from him, asking me when I could attend, but I did not
immediately answer it, as I saw his motive for writing in such a way.
After this, Swann’s wife called upon me and I did attend, and I found the
man discharging mucous from every mucous surface. Mr. Crickmay who
happened to be in my house at the time went with me, and also saw the
deceased, and he enquired as to the remedies that had been adopted; we
both thought the man was sinking—his pulse was almost imperceptible at
the wrist—his eye was vacant—the surface of his skin was clammy, and
there were other indications of that general decline of power which
frequently precedes death. I naturally inquired what the man had been
taking, but before the nurse could answer, he said “he has been giving me
more poison, I know it was arsenic, because I have mixed arsenic and lime
with wheat, and know the smell and taste too.” This is the condition I
found him in—I prescribed for him, directing such treatment as I
conceived to be required to meet the exigencies of the case. He
continued much in the same state for four or five days, the principal
symptoms being diarrhoea, and a discharge of a small quantity of urine,
mixed with bloody mucous and pus, which he had great difficulty in
voiding. He then rallied somewhat, but relapsed in a day or two, and
fearing the threatened result, and being influenced by the remarks being
made out of doors, which were loud and condemnatory of the treatment the
man had received from Dr. Bell, I thought it necessary to call in Mr.
Gibson, a medical man, with whom I was not intimate. On the evening on
which Mr. Gibson saw the man, he supported him while I drew off his
water, and after Mr. Gibson had examined him, he came to the same
conclusion as myself, that abscesses were forming in the neck of the
bladder, and in the tissues connecting that organ with the adjacent
structures. Mr. Gibson said that he had nothing to suggest in addition
to my treatment. He saw the man the next day, and he said there was
evidence of abscesses having burst, both in the rectum and in the
urethra, for a great deal of pus had escaped. For a few days the man
rallied again, but we had no hope for him at that time; and those who
understand these cases, will tell you, that when abscesses form, as the
result of injury and irritation in structures adjacent to the bladder and
its connections, they will, by a continuous irritation in the absence of
controul, lead to the perpetuation or encroachment of similar action in
similar tissues, as for instance, an abscess in the capsule of the
kidney, which has been attested to by Mr. John Coleby as the proximate
cause of death. {55} From that time however, the man gradually
progressed, and thanks to good watching, good nursing, and a generous
diet, he recovered sufficiently to be removed home, not with my consent,
but from frequent importunities I submitted to his going home, and he
having improved, to a certain extent, I told him that he was at liberty
to please himself, as to the future; he could either be under Mr.
Coleby’s care, or he might return to me, and he went home on the 30th of
March. I heard no more of him for a fortnight, when he sent word to me
he was going on well, and that he hoped to return to undergo the
operation. From the cause before mentioned, and possibly owing to the
less nutritious diet, another abscess formed—after this, it appears the
vital powers began to sink.”
Dr. Bell declined cross-examining Mr. Webber, and no other evidence being
called, the room was then cleared of strangers and witnesses, and the
jury proceeded to consider their verdict; after deliberating about 20
minutes, the foreman returned the following verdict:—“_That William Swann
died from an abscess in the capsule of the left bladder_,” but on the
suggestion of Mr. Crickmay, the coroner substituted the word “kidney” for
“bladder,” remarking that, that was what the jury intended. One of the
jury said that the foreman had not given the verdict exactly as agreed
upon; and the foreman then added the words “_and we are of opinion that
deceased’s death was accelerated by improper treatment_.” {56} Mr.
Crickmay said, by whom do you consider improper treatment was used? The
coroner observed “_as for that_, _you and the public are to form your own
judgment_.”
Thus terminated a painful enquiry, on which a large volume might be
written in behalf of humanity, expressing regret, for the sufferings of
the unfortunate deceased—expressing regret that his care, his counsel,
and his regard shown to his wife and children should be so untimely
lost—expressing regret that the good intentions of Mrs. Shirley should
apparently, through misplaced confidence, be frustrated—expressing
regret, that a professional gentleman standing in this case in an awkward
position, should make a more awkward defence, in apparently endeavouring
to cast the blame on others, who wholly undeserved it—expressing regret
that a member of the Royal College of Surgeons, in Ireland, {57a} who is
supposed to possess an acquaintance with the tissues and structures of
the human body, apparently forgot that the larger an instrument, called a
sound, can enter a canal at a given part, the less danger there is of
rupturing a tube, or wounding a delicate membrane. But above all,
expressing regret, that having apparently neglected the precaution given
by Mr. Webber not to use force; having witnessed the agony accompanying
inflammatory action which followed, he persisted to combat it by such
apparently vague medical treatment. {57b} For this it appears was nearly
sending Swann to a still earlier grave. His life, however was for a time
preserved through the skill and perseverance of Mr. Webber, and the great
attention Mrs. Phillips, the nurse, paid to the deceased. But the days
of the poor agricultural labourer were numbered; and his earthly
sufferings having ceased, an earnest hope may be expressed that his
ethereal spirit—his soul, may be now slumbering in the bosom of his
Father, and his God.
The cases narrated, plainly demonstrate that care, tact, delicacy, and
discernment, are required at coroners’ inquests—for a two-fold object
must be kept in view:—the one to ascertain the proximate cause of death,
whether arising from natural or mechanical events, and the other, whether
the law can take cognizance of, and bring to justice the incautious, the
ill-disposed, and possibly the gross offender against the laws of his
country.
To the departed, these duties are of little moment, but to the living,
they demand the greatest attention, not the less owing to the voice of
humanity towards the friends of the deceased than to individuals, who
innocent or guilty, may be directly or indirectly, suspected or
implicated, in conniving or hastening, the death of a fellow creature.
It may be inferred, that jurymen {58} ought to assert their right {59a}
(whilst the memories of learned coroners are sleeping) to ask questions,
necessary to obtain evidence, that their minds may be so enlightened, as
to record just and complete verdicts, even in Mala Praxis, for why should
truth be withheld, when the Science of Medicine, with sound surgery for
its helpmate, are being sullied in glory?
But it must be borne in mind, that a jury of men labouring in other
vocations, living in a remote village, seldom attending coroners’
inquests, whose education is so limited, as not to be competent to seek
for information, which the knowledge of medical jurisprudence inculcates,
are the reasons why they must and do rely on the coroner to extract the
evidence required; that their ideas of right and wrong may rest on the
solid foundation of truth itself, which cannot be effected, unless the
judge on obtaining evidence, explains the law bearing on the question,
and introduces both, suitably to their comprehension. {59b}
Unless this object is realized, coroners’ inquests are perfectly useless,
and evidently prove there must be something “rotten in the state of
Denmark,” which if enquired into, will be found to prevail in many
instances even where gentlemen in the legal profession are coroners. But
how can it be otherwise? Their knowledge of medical jurisprudence, if to
a certain extent comprehended, must be far too limited to conduct
enquiries of grave importance. The want of sound medical knowledge must
prove the hindrance, because it is frequently observed when medical
gentlemen give evidence, they use technicalities employed in the
profession, and by stepping into details, they bewilder their hearers,
and sometimes themselves also. {60} Therefore it may be assumed, that
great tact and discrimination is required in the examination in any case
where medical evidence is of paramount importance, and consequently it
may be believed, that unless gentlemen are properly educated, so as to be
able to elicit important truths connected with the science of medicine in
all its branches, as well as the legal points in coronership, they cannot
be capable of conducting inquiries, in all the integrity, which these
solemn occasions demand.
In conclusion, the following queries may not be deemed impertinent or
superfluous:—
Is it customary for coroners to be petulant, irascible, and over desirous
to close their enquiries?
Is it customary for witnesses to omit signing the depositions of their
evidences?
Is it customary for coroners to allow disputations to exist in their
presence, which do not appear to harmonize with the solemn character of
coroners’ courts?
Is it customary with coroners to omit calling evidence that might be
material towards corroborating testimonies where conflicting evidences
arise, or links in the chain of evidence are broken?
Is it customary for coroners previous to summing up, to order their
courts to be cleared of witnesses, strangers, and reporters, who had been
admitted to hear the evidence?
Is it customary for coroners to summon witnesses _in person_, especially
in cases of adjournment, where grave evidence has previously been given
on oath?
Is it customary for coroners at adjourned inquests, to call upon parties,
in person, suspected of felony, to inform them of it?
Is it customary for coroners to allow suspected parties present at
inquests, to hold earnest conversation with jurymen, during enquiry?
In inquests of grave importance, is it advisable for coroners to summon
jurymen all of one parish, especially if the jurymen are directly or
indirectly connected with parties accessory before the facts, in cases of
suspected felony?
If coroners doubt the veracity of a medical witness, and they state their
reasons for doing so, are they not bound to suggest to the jury the
propriety of calling other medical witnesses?
Is it customary for coroners to omit to recapitulate the evidence at the
summing up, and neglect to explain the bearings of the law upon the
various issues?
Is it customary for coroners to dictate verdicts, instead of leaving
juries to come to their own unbiassed, deliberate, and honest
conclusions?
* * * * *
[Picture: Decorative graphic ‘finis’]
* * * * *
S. DAYNES, PRINTER, NORWICH.
ADVERTISEMENT.
BY THE SAME AUTHOR:
ABOUT TO BE PUBLISHED BY SUBSCRIPTION,
UNDER DISTINGUISHED PATRONAGE.
Revised and considerably enlarged, a Second Edition of
AN ESSAY
ON THE
ENCROACHMENTS OF THE GERMAN OCEAN,
WITH A
Design to arrest its further depredations, applicable to the
Norfolk and other Coasts, by taking every particular
respecting them into consideration.
* * * * *
THE Work will be interspersed with elaborate drawings of Cromer,
Hasborough, &c., accompanied with diagrams, showing the full extent and
meaning of the author, who, owing to repeated solicitation to introduce
another Edition, and having obtained valuable and more ample information,
announces his intention to comply, believing that this important subject
may yet become, as it ought to do, a matter for national attention, and
national expense.
The interested therefore are respectfully informed, that if they coincide
in the desire they expressed, and the offer proposed, orders must be sent
as early as possible, direct to the author, North Walsham, Norfolk.
The Work will be published in Royal quarto.
* * * * *
Price to Subscribers, £1 1s. 0d.—Non Subscribers, £2 2s. 0d.
* * * * *
OPINIONS of the PRESS on the FIRST EDITION.
“The work is another interesting addition to Norfolk literature, and
the plan for the conservation of our Northern shores, is worthy
attention, as coming from a gentleman, who, to some experience at
least, adds the claim of having paid considerable attention to a
subject of no little importance to the Northern and Eastern districts
of the County.”
_Norwich Mercury_.
“The subject of this Essay is indeed of prime importance—First in a
national point of view, as embracing particularly the interest of the
public, and concerning in the closest manner the preservation of all
the property of individuals situated on the contour of the coast of
Norfolk, from the North Westerly point at Wells, to the Haven of
Great Yarmouth.
“The main object of the enquiry is to discover the best plan of
restraining the ravages of the sea, during the periods of
extraordinary high tides; and on this point we entirely agree with
Mr. Hewitt’s general view, and are strongly inclined to believe that
it will answer in most cases where it may be judiciously carried into
effect”
_Norfolk News_.
“The publication of this volume may be considered well timed. It
contains much information respecting the tides and currents of the
ocean—the formation of the Norfolk Coast—the damage done by
irruptions of the sea, &c. We are no engineers, therefore we do not
pretend to pronounce upon the merits of Mr. Hewitt’s plan for the
construction of jetties, breakwaters, &c.; but it appears feasible,
and merits the consideration of those whose property has been, and is
threatened to be injured by the incursions of the ocean. And we
consider the work (which is dedicated to the Lords of the Admiralty,)
to be creditable to the industry of the Author.”
_Norfolk Chronicle_.
“The author is a gentleman, whose profession (a surgeon,) could
hardly be supposed to allow him much time to devote to a subject such
earnest thought and investigation, as the one he has here attacked.
Mr. Hewitt, however, has evidently applied himself to this question
con amore, and the work now before us evinces that he has brought to
its consideration, a mind capable of patient and careful research
into the many and varied causes that bear upon it. Though undertaken
more especially with a view to searching out and propounding a remedy
for the locality of which it immediately treats, a considerable
portion of the work refers to the Encroachments of the Ocean
generally, upon all exposed points of the coast, and there is much in
it that would apply to the Southern, as forcibly as to the Eastern
coast
“Mr. Hewitt describes the plan which he recommends as the best mode
of imposing a check to the Encroachments of the Ocean, and shows the
supposed elevation of the beach from the deposit of sand likely to be
caused by the inventor’s plan.
“The work is written in an earnest, but modest and unpretending
style, and the aim of the author is so good and praiseworthy, that
should it fail to make the impression on head quarters, desired by
its writer, he will, under all circumstances, have the satisfaction
of feeling that he has laboured in a good cause. While other minds
may perhaps entertain different views as to the utility or
practicability of his scheme, they cannot fail to admit Mr. Hewitt
deserves the thanks of his country, for the benevolent motives which
have actuated, and the patient and diligent care which has directed
his efforts in the field in which he has thus become a labourer.”
_Sussex Advertiser_, _and Surrey Gazette_.
“A remarkable ‘Essay’ which has met with the usual attention bestowed
upon Cassandric warnings.”
_Dickens’ Household Words_.
FOOTNOTES.
{7} Those havens that lie towards France, and have been thought by our
kings to be such as ought most vigilantly to be observed against
invasion. In which respect, the places where they have a special
governor or keeper, called by his office, Lord Warden of the _Cinque
Ports_; and various privileges granted to them, as a particular
jurisdiction; their Warden have an authority among them, and sending out
writs in his own name. The Ports are Dover, Sandwich, Rye, Hastings,
Winchelsea, Romney and Hithe. Some of which as the number exceeds five,
must either be added to the first institution by some later grant or
accounted as appendant to some of the rest.
{17} _Vide_ Sewell, on the Law of Coroners.
{28} What were the tests applied, to prove that Laudanum had been
administered to the infant? If the child did not die from the effects of
Laudanum, what caused its death?
{32} Lord Lyndhurst, in a recent case, laid down the following rule:—
“In these cases there is no difference between a licensed physician
or surgeon, and a person acting as physician or surgeon without
license. In either case, if a party having a competent degree of
skill and knowledge, makes an accidental mistake in the treatment of
a patient, through which mistake death ensues, he is not thereby
guilty of manslaughter.”
“But if where proper medical assistance can be had, a person totally
ignorant of the science of medicine—takes on himself a violent and
dangerous remedy to one labouring under disease, and death ensues in
consequence of that dangerous remedy having been so administered,
then he is guilty of manslaughter; or a man may be guilty of
manslaughter if, notwithstanding _he has a competent knowledge of
medicine_, _he be guilty of gross rashness in the application of a
remedy or gross negligence in attending his patient afterwards_.
Also, where a man doing a lawful act, which is at the same time
dangerous, he neglects to use _proper caution_, death ensues, if it
takes place within a _twelve month_ and a day; but if his life
exceeds that period, the law will presume that his death proceeded
from some other cause than the wound.”—1 Hawk, P. C. 23 s. 90.
“If a man be sick of a disease which in all likelihoods would
terminate his life, and another give him a _wound or hurt which
hastens_ his _death_, this is such a killing as would constitute
murder.”—See 1 Lord Hale, 428.—_Vide_ Sewell, on the Law of Coroners.
{39} A term given to a fluid attending suppuration, one of the
consequences of inflammatory action.
{46} In the course of the enquiry, the coroner remarked he did not know
who might have got up that inquest, and that had he been apprised of it,
he should have _appointed some person unacquainted with the deceased and
the circumstances_, to have made the post mortem examination. Mr. Webber
observed, “Sir, you cannot be in doubt upon that score, as you must
admit, on the 15th of May, I enclosed you a note from Mr. Pilgrim, your
brother coroner, to whom, supposing him to have been the coroner for the
district, I mentioned all the circumstances connected with the deceased,
and he conceived it was a proper case, in justice to all parties, that an
inquiry should take place; and sir, I apprehend I have done your friend,
on your left, no injustice, by getting his own friend Mr. Coleby to
examine the body, for you cannot suppose, that the very cordial manner in
which you saw Mr. Coleby shake Dr. Bell by the hand, he could have had
any unfair or ill feeling towards him.”
{49} This was a new instrument, admirably adapted for the detection of
stone, lately invented by Mr. Webber, and manufactured by Ferguson, of
Smithfield.
{52} Nux. _Nux Vomica Strichnia_. This is a well-known remedy as a
theraputic agent in cases of paralysis. If this, or other medicines used
by Dr. Bell, aggravated the misery of the sufferer, possibly that
gentleman, who it appears was educated in the Allopathic School, might
have used them in larger doses than is prescribed by a real disciple of
the German Hahnemann. Be this as it may, it furnishes a precious example
to those who follow such vague practise in grave disease, where the life
of the afflicted verges on eternity. Yet, surely, none but vain and
ignorant people, assumed or real, can believe in the shadow of a shade,
though introduced with all the seductive novelty which specious artifice
and subtle ingenuity can devise, as promulgated in the doctrines of a
visionary enthusiast and his followers.
{55} Metastasis or translation of disease frequently takes place at a
remote distance from the original seat of mischief, involving tissues
belonging to vital organs, and the afflicted sink through inanition or
loss of vital power.
{56} A verdict is altogether a matter of substance. All the facts and
circumstances must be stated with certainty and precision, without any
repugnancy or inconsistency; and where it contains a charge, the charge
must be direct and positive.—Vide Sewell on the Law of Coroners.
{57a} So stated in the Medical Directory.
{57b} This forms the nucleus for other observations, at a convenient
opportunity.
{58} The jury are to inquire into and judge of all matters of fact
connected with the death of a party, and in certain cases of flight,
forfeiture, deodands, &c. and for that purpose to receive such evidence
as may appear necessary. But they may give a verdict without testimony,
where they themselves have cognizance of the fact; but if they give a
verdict on their own knowledge, they ought to inform the court so. They
may however be sworn as witnesses, and the fair way is to tell the court
before they are sworn, that they have evidence to give.
{59a} According to Lyttleton, in which opinion Lord Coke concurs, if the
jury will take upon themselves the knowledge of the law, the coroner is
bound to accept the presentment which the jury make.
{59b} But it appears (and very judiciously so) that the immediate and
direct right of deciding upon questions of law is entrusted to the court,
while in the jury, it is at most only incidental; that in the exercise of
this incidental right, the latter are not only placed under the
superintendence of the former, but in some degree controllable by them;
and therefore, that in all points of law during an investigation, the
jury ought to show the most respectful deference to the advice and
recommendation of the court.—_Vide_ Sewell on the law of coroners.
{60} Each Art and Science has its technicalities, which must be used to
designate the component parts severally connected with a whole.
Therefore, if hearers, particularly judges, do not understand evidence
minutely given by medical gentlemen: the latter become confused, owing to
using language perfectly comprehensible to themselves, but provokingly
incomprehensible to others.
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