Observations on Coroners

by William Hewitt

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.