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Autopsies for the Coroner
388
pathologist who is’to be found at every reputable hospital of importance is a proper person to undertake the ordinary run of coroner’s work, but for the case which has or may have criminological repercussions the services of a pathologist specialising in
transmitters of infection than was thought, and there is little doubt that isolation when put into practice must -be of the strictest and extended to outdoor as well as indoor contacts.
The
for the Coroner IN a coroner’s court a general practitioner lately protested against having been called on to perform an autopsy which he claimed required the skill and experience of a competent pathologist.i The examination had proved difficult, and in spite of the help of an analyst the court was left in doubt as to the precise cause of death. The coroner explained that the nearest pathologist was many miles away and that it seemed unreasonable to ask him to make a special journey when there were several doctors already in the town. Many coroners lack a medical qualification, so they may be excused if they do not always appreciate the difficulty which even a skilled - pathologist may find in explaining a death in terms of pathology. It is the coroner’s business to find out whether the subject of the inquiry has died a natural or unnatural death ; he is not interested in the pathological process
forensic work are desirable. These men are scarce, and are to be found in the larger centres only; but their special experience of crime detection and the vituperations of opposing barristers fits them for this important work, where justice, in its quest for retribution, may demand the lives of citizens. The general practitioner who objected to being called on to perform an autopsy was therefore correct in his contention and is to be congratulated on the courageous way he spoke out in public. Too often in the past a general practitioner has embarked on a cursory examination without declaring his lack of experience. The coroner had good reason for acting as he did. He did not want to bother a pathologist whose day he probably knew to be full. It was a long way for the pathologist to come ; and his examination would cost the local authority more than one by a local man. The coroner’s views, however, commendable though they are, emphasise the need for drastic revision of the present attitude of some coroners and local authorities. Why should not the sent have been to the post-mortem room in the body Bodies can be moved from the pathologist’s hospital ? area of jurisdiction of one coroner into that of another by mutual arrangement. The reason no doubt was that of expense, for until he is reimbursed by the local authority a coroner must pay fees like these out of his own purse ; and because a pathologist’s charges and travelling expenses are curtailed by
as
Autopsies
which has been at work. But by now there cannot be many coroners who still believe- that it requires " just a peep inside " to determine the cause of death. Gross changes in morbid anatomy may call forth a whistle of exclamation from the attending constable, even if his previous experience of pathology has been confined to casual acquaintance with the nearest abattoir ; but the telltale pin-headsubintimal hoemorrhage in the branch of an atheromatous coronary artery, or the sinister fleck of curd on the larynx of an overfed infant, call for skilful observation founded on long experience. It is understandable why the Home Office departmental committee on coroners recommended ten years ago that " autopsies should be undertaken by pathologists with special experience in that class of work," adding that " this must apply to all post-mortem examinations made at the request of coroners " ; the pity is that so few coroners seem to be familiar with this recommendation. But the coroner must retain his full freedom and employ anybody he wants. It must never be laid down that a coroner is under an obligation to employ any one medical practitioner, be he a pathologist or not. Neither is it desirable that the coroner’s powers of direction as laid down in the Coroners Act of 1887, and in the Coroners (Amendment) Act of 1926, should be repealed, for circumstances might arise when no doctor could be found who would be prepared to carry out an autopsy. Under this Act the coroner can summon the doctor who attended the deceased at the time of death, or if the deceased had not before death been attended by a doctor he can summon a practitioner in or near the place where death It has apparently never been decided occurred. whether a pathologist residing or practising ten miles a practitioner near the place where death away is occurred," but the Act of 1926 enables coroners to request specially qualified doctors to perform postmortem examinations and report to them. Such a specially qualified doctor is of necessity a pathologist, and there are few parts of the United Kingdom where the services of such a person are not within reach. "
1. Western
Morning News, Feb. 2, 1946.
statute it is cheaper to invite a pathologist to move over with his assistant and all the equipment of the post-mortem room than to hire an undertaker to move the body to the pathologist’s hospital. This is a lamentable state of affairs and shows how little value is attached to an autopsy by some local authorities who should know better. The difficulty might easily be overcome if local authorities asked undertakers to tender for this class of work. Within an hour or two of the body being brought to the
the pathologist will have completed his examination and the corpse will be on its way back to the parish mortuary or lying in the hospital mortuary awaiting the completion of burial arrangements. Under this plan pathologists would no longer have to work, as they are sometimes expected to do, in sheds adjoining pig-swill plants or knacker’s or in blacked-out outhouses shops, in frigid barns, of corporation yards.2 A wise pathologist will refuse to work in a post-mortem room which is not equipped with a good north light, running water, and adequate ventilation and heating. The hospital post-mortem room possesses the additional advantages of proper equipment, bone saws, and access to laboratories and X-ray plant. Under these conditions not only will the pathologist make a more satisfactory examination but he will be spared time-consuming and tiring
hospital,
journeys. The objections
which have been raised are all surmountable. First, it may be distressing for relatives to know that the body of a dear one is being 2. See In
England Now, Lancet, 1942, i, 237.
389
But if
they realise that an examination is they not want it to be done properly in respectable premises ? Secondly, the doctor in attendance may want to see the autopsy. In practice moved.
necessary would
he seldom has the necessary time, but if he has he will not object to visiting the hospital. The pathologist will preserve the specimens for him to see later if he wishes, and with the coroner’s approval will furnish a copy of the report. Lastly, will the hospital authorities welcome an additional stream of hearses invading their premises ? An enlightened committee will not object to a scheme which lightens the load on their pathologist while making his work more effective.
Annotations TREATMENT OF PETIT MAL EVERYONE who has been responsible for the treatment has noticed that results vary in individual and that attacks which are different in their patients, clinical patterns also differ in their therapeutic response. Petit mal in particular shows a resistance to drugs which is not shared by other types of epilepsy. Lennox1 .has again emphasised the fundamental difference between the three main groups of epileptic disturbance-petit .mal, grand mal, and the psychomotor attacks. He points out that petit mal differs from the other types in the time of onset, course, and response to physiological changes. He also asserts that petit mal, as he defines it, is rarely if ever a symptom of gross cerebral damage-it is a constitutional disorder. With all this there is fairly general agreement. One of the most striking differences between the clinical forms of epilepsy is seen in the electrical accompaniments of the attacks recorded in the electroencephalogram, and it is on these changes that Lennox makes his most distinct differentiation of the types of epilepsy. The term petit mal was originally used to describe any small attack, in contradistinction to grand malminor and major epilepsy in the English tongue. Now, thanks largely to the evidence of the electroencephalograph, petit mal itself has been divided into different types which have distinct electroencephalographic and clinical features, so that for want of a more scientific terminology one refers, for example, to pure petit mal " " small grand mal." The difference as opposed to between these two conditions may be trivial to the clinical observer, but is extreme when their electrical counterparts are studied in the electroencephalogram, and the distinction must be made whenever possible, for the treatment of choice for each is different. It was a pity that the old-established, inadequate, clinical terminology was applied by the American workers to the electroencephalographic changes which seemed to accompany the different kinds of attack, for this has caused some confusion and misunderstanding. Lennox tries to get around the difficulty with neologisms, and even uses the synonyms " petit mal, pyknolepilepsy, and dart and dome dysrhythmia " in an attempt to link the old and the new ; but it is time that the whole question of classification and nomenclature in epilepsy was re-examined by a group of authorities whose recommendations would be generally acceptable. Lennox recognises three clinical types of petit mal as seen in the electroencephalogram-a disturbance associated with alternating fast and slow waves (wave and spike complexes). These are " pure " petit mal, in which there is simply loss of consciousness ; myoclonic epilepsy with muscular jerking ; and akinetic epilepsy, in which there is a sudden loss of postural control. Besides the similar kind of disturbance which these attacks cause
of
epilepsy
"
1.
Lennox, W. G.
J. Amer. med. Ass. 1945, 129, 1069.
in the electroencephalogram, they have other common features which include their failure to respond satisfactorily to the accepted methods of treating epilepsy. Their response to bromides and phenobarbitone is not good, and the hydantoins are usually ineffective. On the other hand caffeine and amphetamine, which have no value in other epileptic disorders, produce some improvement. Lennox has found that a drug, 3, 5, 5trimethyloxazolidine-2, 4-dione, which is shortened to tridione, has given better results than any other he has used. His claims are still tentative, for he has treated only 50 patients for periods of 2-15 months, and he reports the results in only 40 of these. All these 40 patients showed spike and wave complexes in the E.E.G., and, he says, " practically all of the group had been given the usual anticonvulsant drugs without benefit " ; 11of the group are now free from attacks, and in 21 the average number of attacks has fallen to a quarter or less of its former value. In every patient there was some improvement, but in 2 the drug was stopped because of toxic enects. There is a suggestion from the results that attacks do not return when treatment ceases, but since petit mal attacks tend to disappear with age and to vary in their frequency, this may be the result of chance. The present report is a preliminary one, but it suggests that at the very worst tridione will repay careful and extended trial. REDUCED RATIONS FOR GERMANY THE Minister responsible for the British zone of Germany, Mr. John Hynd, is reported as saying last Sunday that unless 150,000 tons of food arrive before the end of the month the daily ration will not be 1000 calories but 700 or even 450. And it is impossible, he thought, to move the 150,000 tons in time; the most that can go to Germany is 30,000 tons. In view of the dangerous situation that is evidently developing we should like to be assured at least that any failure to avert mass starvation in the next six weeks or two months " among the 23 million inhabitants of the zone will be due to physical causes and not to a state of mind which will later be regretted.Some of the statements so far made are not reassuring in this respect. FieldMarshal Montgomery, who was not perhaps in possession of the latest information, said on March 8: "I have had to reduce the German rations to 1000 calories We per head, compared with 2800 in this country. will keep them at 1000. The Germans gave the inmates of Belsen only 800 calories." He added that " for years and years the Germans have lived very well indeed and I would not take any food from England in order to feed the Germans, nor will there be any taken.... We are looking after the children, but the big overgrown Germans have got to tighten their belts."1 His deputy in Germany, Sir Brian Robertson, is credited with the remark that although Britain considers that the Germans should be adequately fed, this is not because she is sorry for them but because it is " a matter of policy." Certainly there are ample political grounds for preventing starvation in the British zone in Germany; on a diet yielding under 1000 calories the population could do little work and- would further depend on our support. But if the people of this country were made to understand the world of difference between our present monotonous diet and a Belsen standard (plus or minus a couple of hundred calories), they would surely remember that there are other reasons too. Mr. Victor Gollancz1 is right when he sees some recent public utterances as examples of " that contempt for mercy and that glorification of ’self-interest and expediency which are rapidly becoming the new morality, and which are an utter denial of the teachings of Christianity and of Judaism before it." The habit of thinking about people in almost meaningless abstractions-of " the Germans " 1. Manchester
Guardian,
March 9.
pathologist who is’to be found at every reputable hospital of importance is a proper person to undertake the ordinary run of coroner’s work, but for the case which has or may have criminological repercussions the services of a pathologist specialising in
transmitters of infection than was thought, and there is little doubt that isolation when put into practice must -be of the strictest and extended to outdoor as well as indoor contacts.
The
for the Coroner IN a coroner’s court a general practitioner lately protested against having been called on to perform an autopsy which he claimed required the skill and experience of a competent pathologist.i The examination had proved difficult, and in spite of the help of an analyst the court was left in doubt as to the precise cause of death. The coroner explained that the nearest pathologist was many miles away and that it seemed unreasonable to ask him to make a special journey when there were several doctors already in the town. Many coroners lack a medical qualification, so they may be excused if they do not always appreciate the difficulty which even a skilled - pathologist may find in explaining a death in terms of pathology. It is the coroner’s business to find out whether the subject of the inquiry has died a natural or unnatural death ; he is not interested in the pathological process
forensic work are desirable. These men are scarce, and are to be found in the larger centres only; but their special experience of crime detection and the vituperations of opposing barristers fits them for this important work, where justice, in its quest for retribution, may demand the lives of citizens. The general practitioner who objected to being called on to perform an autopsy was therefore correct in his contention and is to be congratulated on the courageous way he spoke out in public. Too often in the past a general practitioner has embarked on a cursory examination without declaring his lack of experience. The coroner had good reason for acting as he did. He did not want to bother a pathologist whose day he probably knew to be full. It was a long way for the pathologist to come ; and his examination would cost the local authority more than one by a local man. The coroner’s views, however, commendable though they are, emphasise the need for drastic revision of the present attitude of some coroners and local authorities. Why should not the sent have been to the post-mortem room in the body Bodies can be moved from the pathologist’s hospital ? area of jurisdiction of one coroner into that of another by mutual arrangement. The reason no doubt was that of expense, for until he is reimbursed by the local authority a coroner must pay fees like these out of his own purse ; and because a pathologist’s charges and travelling expenses are curtailed by
as
Autopsies
which has been at work. But by now there cannot be many coroners who still believe- that it requires " just a peep inside " to determine the cause of death. Gross changes in morbid anatomy may call forth a whistle of exclamation from the attending constable, even if his previous experience of pathology has been confined to casual acquaintance with the nearest abattoir ; but the telltale pin-headsubintimal hoemorrhage in the branch of an atheromatous coronary artery, or the sinister fleck of curd on the larynx of an overfed infant, call for skilful observation founded on long experience. It is understandable why the Home Office departmental committee on coroners recommended ten years ago that " autopsies should be undertaken by pathologists with special experience in that class of work," adding that " this must apply to all post-mortem examinations made at the request of coroners " ; the pity is that so few coroners seem to be familiar with this recommendation. But the coroner must retain his full freedom and employ anybody he wants. It must never be laid down that a coroner is under an obligation to employ any one medical practitioner, be he a pathologist or not. Neither is it desirable that the coroner’s powers of direction as laid down in the Coroners Act of 1887, and in the Coroners (Amendment) Act of 1926, should be repealed, for circumstances might arise when no doctor could be found who would be prepared to carry out an autopsy. Under this Act the coroner can summon the doctor who attended the deceased at the time of death, or if the deceased had not before death been attended by a doctor he can summon a practitioner in or near the place where death It has apparently never been decided occurred. whether a pathologist residing or practising ten miles a practitioner near the place where death away is occurred," but the Act of 1926 enables coroners to request specially qualified doctors to perform postmortem examinations and report to them. Such a specially qualified doctor is of necessity a pathologist, and there are few parts of the United Kingdom where the services of such a person are not within reach. "
1. Western
Morning News, Feb. 2, 1946.
statute it is cheaper to invite a pathologist to move over with his assistant and all the equipment of the post-mortem room than to hire an undertaker to move the body to the pathologist’s hospital. This is a lamentable state of affairs and shows how little value is attached to an autopsy by some local authorities who should know better. The difficulty might easily be overcome if local authorities asked undertakers to tender for this class of work. Within an hour or two of the body being brought to the
the pathologist will have completed his examination and the corpse will be on its way back to the parish mortuary or lying in the hospital mortuary awaiting the completion of burial arrangements. Under this plan pathologists would no longer have to work, as they are sometimes expected to do, in sheds adjoining pig-swill plants or knacker’s or in blacked-out outhouses shops, in frigid barns, of corporation yards.2 A wise pathologist will refuse to work in a post-mortem room which is not equipped with a good north light, running water, and adequate ventilation and heating. The hospital post-mortem room possesses the additional advantages of proper equipment, bone saws, and access to laboratories and X-ray plant. Under these conditions not only will the pathologist make a more satisfactory examination but he will be spared time-consuming and tiring
hospital,
journeys. The objections
which have been raised are all surmountable. First, it may be distressing for relatives to know that the body of a dear one is being 2. See In
England Now, Lancet, 1942, i, 237.
389
But if
they realise that an examination is they not want it to be done properly in respectable premises ? Secondly, the doctor in attendance may want to see the autopsy. In practice moved.
necessary would
he seldom has the necessary time, but if he has he will not object to visiting the hospital. The pathologist will preserve the specimens for him to see later if he wishes, and with the coroner’s approval will furnish a copy of the report. Lastly, will the hospital authorities welcome an additional stream of hearses invading their premises ? An enlightened committee will not object to a scheme which lightens the load on their pathologist while making his work more effective.
Annotations TREATMENT OF PETIT MAL EVERYONE who has been responsible for the treatment has noticed that results vary in individual and that attacks which are different in their patients, clinical patterns also differ in their therapeutic response. Petit mal in particular shows a resistance to drugs which is not shared by other types of epilepsy. Lennox1 .has again emphasised the fundamental difference between the three main groups of epileptic disturbance-petit .mal, grand mal, and the psychomotor attacks. He points out that petit mal differs from the other types in the time of onset, course, and response to physiological changes. He also asserts that petit mal, as he defines it, is rarely if ever a symptom of gross cerebral damage-it is a constitutional disorder. With all this there is fairly general agreement. One of the most striking differences between the clinical forms of epilepsy is seen in the electrical accompaniments of the attacks recorded in the electroencephalogram, and it is on these changes that Lennox makes his most distinct differentiation of the types of epilepsy. The term petit mal was originally used to describe any small attack, in contradistinction to grand malminor and major epilepsy in the English tongue. Now, thanks largely to the evidence of the electroencephalograph, petit mal itself has been divided into different types which have distinct electroencephalographic and clinical features, so that for want of a more scientific terminology one refers, for example, to pure petit mal " " small grand mal." The difference as opposed to between these two conditions may be trivial to the clinical observer, but is extreme when their electrical counterparts are studied in the electroencephalogram, and the distinction must be made whenever possible, for the treatment of choice for each is different. It was a pity that the old-established, inadequate, clinical terminology was applied by the American workers to the electroencephalographic changes which seemed to accompany the different kinds of attack, for this has caused some confusion and misunderstanding. Lennox tries to get around the difficulty with neologisms, and even uses the synonyms " petit mal, pyknolepilepsy, and dart and dome dysrhythmia " in an attempt to link the old and the new ; but it is time that the whole question of classification and nomenclature in epilepsy was re-examined by a group of authorities whose recommendations would be generally acceptable. Lennox recognises three clinical types of petit mal as seen in the electroencephalogram-a disturbance associated with alternating fast and slow waves (wave and spike complexes). These are " pure " petit mal, in which there is simply loss of consciousness ; myoclonic epilepsy with muscular jerking ; and akinetic epilepsy, in which there is a sudden loss of postural control. Besides the similar kind of disturbance which these attacks cause
of
epilepsy
"
1.
Lennox, W. G.
J. Amer. med. Ass. 1945, 129, 1069.
in the electroencephalogram, they have other common features which include their failure to respond satisfactorily to the accepted methods of treating epilepsy. Their response to bromides and phenobarbitone is not good, and the hydantoins are usually ineffective. On the other hand caffeine and amphetamine, which have no value in other epileptic disorders, produce some improvement. Lennox has found that a drug, 3, 5, 5trimethyloxazolidine-2, 4-dione, which is shortened to tridione, has given better results than any other he has used. His claims are still tentative, for he has treated only 50 patients for periods of 2-15 months, and he reports the results in only 40 of these. All these 40 patients showed spike and wave complexes in the E.E.G., and, he says, " practically all of the group had been given the usual anticonvulsant drugs without benefit " ; 11of the group are now free from attacks, and in 21 the average number of attacks has fallen to a quarter or less of its former value. In every patient there was some improvement, but in 2 the drug was stopped because of toxic enects. There is a suggestion from the results that attacks do not return when treatment ceases, but since petit mal attacks tend to disappear with age and to vary in their frequency, this may be the result of chance. The present report is a preliminary one, but it suggests that at the very worst tridione will repay careful and extended trial. REDUCED RATIONS FOR GERMANY THE Minister responsible for the British zone of Germany, Mr. John Hynd, is reported as saying last Sunday that unless 150,000 tons of food arrive before the end of the month the daily ration will not be 1000 calories but 700 or even 450. And it is impossible, he thought, to move the 150,000 tons in time; the most that can go to Germany is 30,000 tons. In view of the dangerous situation that is evidently developing we should like to be assured at least that any failure to avert mass starvation in the next six weeks or two months " among the 23 million inhabitants of the zone will be due to physical causes and not to a state of mind which will later be regretted.Some of the statements so far made are not reassuring in this respect. FieldMarshal Montgomery, who was not perhaps in possession of the latest information, said on March 8: "I have had to reduce the German rations to 1000 calories We per head, compared with 2800 in this country. will keep them at 1000. The Germans gave the inmates of Belsen only 800 calories." He added that " for years and years the Germans have lived very well indeed and I would not take any food from England in order to feed the Germans, nor will there be any taken.... We are looking after the children, but the big overgrown Germans have got to tighten their belts."1 His deputy in Germany, Sir Brian Robertson, is credited with the remark that although Britain considers that the Germans should be adequately fed, this is not because she is sorry for them but because it is " a matter of policy." Certainly there are ample political grounds for preventing starvation in the British zone in Germany; on a diet yielding under 1000 calories the population could do little work and- would further depend on our support. But if the people of this country were made to understand the world of difference between our present monotonous diet and a Belsen standard (plus or minus a couple of hundred calories), they would surely remember that there are other reasons too. Mr. Victor Gollancz1 is right when he sees some recent public utterances as examples of " that contempt for mercy and that glorification of ’self-interest and expediency which are rapidly becoming the new morality, and which are an utter denial of the teachings of Christianity and of Judaism before it." The habit of thinking about people in almost meaningless abstractions-of " the Germans " 1. Manchester
Guardian,
March 9.