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REPORT
ON
SPECIAL EXAMINATION
OF THE


ACCOUNTS and METHODS
OF THE OFFICE OF
CORONER
IN THE CITY OF NEW YORK
DIRECTED BY
Hon. JOHN PURROY MITCHEL, Mayor
X!m, (1OFF CE OF
THE COmMISSIOnER OF ACCOUNTS,
CITY OF NEW YORK


LEONARD M. WALLSTEIN
COMMISSIONER OF ACCOUNTS




1BRQWNF
SNDINO 


73040-14-2000




EXCN ANLC"
mAC~O 'tLcr  t t\BfRT
January 2, 1915.
Hon. JOHN PURROY MITCHEL,
Mayor:
SIR-On June 13, 1914, at the request of the City Club, you ordered
an investigation of the accounts and methods of the Coroners' Office
throughout this city.
Pursuant to your direction, I have been conducting such an investigation through the field staff of this office, and by means of private and public
hearings. Three hundred and ninety witnesses have been examined under
oath and over six thousand pages of testimony taken.
The investigation is not yet completed, but it has proceeded far enough
to demand a report at this time, since it is clear that legislative action alone
can furnish any thorough remedy for the wretched situation which has been
found. I have therefore the honor to transmit such report herewith.
A proposed bill abolishing the present Coroner system in this city and
replacing it by a system of medical examiners similar to that provided in
Massachusetts is now under preparation, and will be submitted to your
Honor at an early date.
At one time the scope of the investigation was in danger of serious
restriction by reason of the position taken by Coroner Herman Hellenstein
of the Manhattan office, who, on the advice of his counsel, Frank Moss,
Esq., challenged the jurisdiction of the Commissioner of Accounts to examine
him as to anything beyond the mere business routine of the Coroners'
Office, and declined to answer questions directed to a real inquiry into his
official conduct. An appeal to the Supreme Court resulted, however, in a
decision by Mr. Justice Newburger reaffirming the jurisdiction of this Commission, and directing the Coroner to answer. Similar proceedings were
necessary and were similarly successful against another witness.
It will, I am sure, be gratifying to your Honor to learn, as it is to me to
be able to report, that very great assistance has been rendered in this investigation not only by the staff of this office, who responded energetically
and enthusiastically to every request made of them, but also by the Police,
Health, Law and Correction Departments of this city, all of which co-operated most effectively.
The suggestion, advice and assistance of Mr. Robert S. Binkerd, Secretary of the City Club, have been likewise most helpful.
Respectfully yours,
LEONARD M. WALLSTEIN,
Commissioner of Accounts.




SUMMARY OF FINDINGS.
The elective coroner in New York City represents a combination of power,
obscurity and irresponsibility which has resulted in inefficiency and mal.
feasance in the administration of the office.
With constant temptation and easy opportunity for favoritism and even
extortion, with utter lack of supervision and control, and without the slightest
preparation and training to create in the coroner's mind a scientific and professional interest in the performance of his duties, the present system could
not have been better devised intentionally to render improbable, if not impossible, the honest and efficient performance of the important public function entrusted to his office.
Of the 65 men who have held the office of coroner since consolidation, not
one was thoroughly qualified by training or experience for the adequate performance of his duties.
The coroner should not be an elective officer, since he has no questions of
public policy to settle.
Candidates for coroner are nominated "to balance the ticket," to represent
a given race, religion, class, political faction or geographical portion of the city.
Thus, almost every consideration except qualification for the position determines
his choice.
Many of the coroners are absurdly ignorant both as to the legal and the
medical aspects of their work.
The type of man usually elected to the office of coroner is entirely unfit for
the exercise of judicial functions, as shown by the general practice of establishing compromising relations with corporations and others who are frequently
involved in litigation before the Coroners' Court.
Many of the coroners admit the general unfitness of the elective coroner.
Most of the coroners' physicians in New York City have been drawn from
the ranks of medical mediocrity.
From the frequent admission of mistakes or of inability to sustain their
medical conclusions, it is clear that such conclusions are without scientific
validity.
Some of the coroners' physicians have favorite causes of death which,
without the shadow of reason, they are in the habit of assigning in cases of
doubt.
The character of their medical examinations may be judged from the fact
that the keeper of the morgue testified that they often merely look at the head
of the body and that an examination lasting five minutes was an infrequent
occurrence.
Several of the coroners either admit the complete inadequacy of the medical
work of the coroners' physicians or entirely distrust them.
The coroners' physician under the present system is a law unto himself
and is subject to no continuous or effective control.
Such disciplinary power as the Manhattan Board of Coroners possesses over
its physicians has been used, not to improve the character of their medical




5


work, but rather to harass and embarrass the most competent of all their
physicians.
One coroner's physician concedes that the coroner's physician "does
about as he pleases with little thorough supervision of a higher authority to hold
him up to the high standard that he should be held up to. I want to plead
guilty and throw myself on the mercy of the court."
A serious result of this lack of supervision is that it facilitates extortion
by coroners' physicians.
The coroners' physicians not infrequently use as the statement of causes
of death terms which modern science has rejected as meaningless.
Far from being of assistance, the death certificates of the coroners' physicians introduce a large degree of error into the vital statistics of the city.
The continued incompetence of coroners' physicians has compelled the
Health Department to accept from them certificates of death which it would
not accept from physicians in private practice.
Many of the coroners' physicians on the witness stand showed not the
slightest concern as to any effect which their work had upon the city's vital
statistics.
An analysis of 800 inquisition papers made by Deputy Health Commissioner Emerson finds that in 320 cases, or forty per cent. of those examined,
there is a complete lack of evidence to justify the certified cause of death.
The incompetent medical work of the coroners' physicians persists in the
investigation of criminal deaths and deprives the community of an absolutely
necessary deterrent to crime.
Numerous homicides have undoubtedly failed of detection by reason of this
fact.
So far as the activity of the coroners' office in New York City is concerned,
infanticide and skillful poisoning can be carried on almost with impunity.
Under the elective coroners' system, and in the face of exceedingly difficult
conditions surrounding successful criminal prosecution, New York City is com.
pelled to get along virtually without aid from the science of legal medicine, a
situation which exists in no other great city in the world.
At least one coroners' physician has no conception of the functions of his
office, denying that it is part of his function in first instance to detect crime by
medical examination.
The system of coroners' juries, both as to law and practice, makes the administration of justice in the Coroners' Court a scandal and a farce.
Coroners' juries can readily be and actually have been packed with friends
of defendants before them.
The system of coroners' juries offers a ready means of petty extortion.
Many of the coroners themselves admit that the coroners' jury is utterly
mischievous and should be abolished.
The records kept by the coroners' office are meagre, uninforming and practically valueless.
In criminal prosecutions the district attorney usually receives no adequate
medical data whatever.




6


In the most important criminal trials, coroners' physicians frequently testify
only from memory.
Though the coroners' records in all cases of suspected crime are required by
law to be filed forthwith with the district attorney, yet in the month of July,
1914, after this investigation was under way, the Board of Coroners of the
Borough of Manhattan filed for the first time with the district attorney of New
York County inquisition papers in 431 cases involving possible criminality.
Sixty=three of these were over three years old and nearly 200 were over one
year old.
In order to obtain effective performance of the work which the coroners'
office should do, the district attorneys of New York and Kings Counties have
organized homicide bureaus in their own offices.
These bureaus make complete and independent investigation in each case.
Through long experience they have come to pay practically no attention to the
coroners' investigations, findings or conclusions.
On the contrary, the district attorneys' investigations are sometimes im=
peded by the bungling interference of the coroner.
In the field of criminal abortion, far from serving to detect crime, the
coroners' system has become an agency for shielding defendants and concealing
criminality.
The same features of the coroners' system which invite this malfeasance
invite similar malfeasance in other fields of crime.
In connection with abortion cases, coroners have called or failed to call
juries as best suited their purposes, have packed juries, have intentionally failed
to call necessary witnesses, or to cause police investigation or to utilize the
results of such investigation when made.
Where the available facts have fairly indicated that death was due to
criminal abortion, coroners have without further investigation attributed death
to causes unknown.
The conduct of Coroner Hellenstein in connection with such cases has been
particularly scandalous.
Coroners have abused their powers to compel the employment of favored
undertakers by the unfortunate families of deceased persons.
Subordinates in the Coroners' Office have made disgusting alliances with
favored undertakers for the purpose of facilitating their employment in coroners'
cases.
Civil rights and liabilities have been profoundly affected by the findings of
the coroner, whose action in many cases has been a travesty on justice.
Attempts have not infrequently been made to extort sums of money from
insurance companies in return for findings in the companies' interest.
Until the enactment of the Workmen's Compensation Law the coroner has
scandalously injured the rights of deceased workmen and has helped to make
for employing corporations cases which would relieve them of liability for their
workmen's deaths.




7


The Coroners' Office is over-manned with unnecessary and political sub.
ordinates at salaries grossly in excess of the value of their services.
The position of private clerk to a coroner is a political sinecure.
No office supported out of the city treasury has been more loath to establish
any system of efficiency records by which could be measured the amount and
efficiency of work rendered.
The chief clerk of the Board of Coroners for the Borough of Manhattan is
a political leader, maintained out of the public treasury, who renders practically
no official service.
Many petty grafts and abuses have become prevalent among employees
of the coroners' system.
The maintenance of the present coroners' system is a sheer waste of public
money amounting to over $172,000 per year.
It costs the city $11,000 a year to pay for the services of a single unqualified
coroner, his mediocre physician and his personal clerk, who spends most of his
time on his own private affairs.
That the elective coroners' system is inevitably productive of great abuse is
likewise demonstrated by the experience of other communities, which have
abolished or attempted to abolish similar systems.
The abuses disclosed by this investigation have been found time and
again in this city and previous attempts to remove them by the abolition of the
coroners' system have been defeated from purely selfish political considerations.
The present coroners' system cannot be continued in this city except as a
public scandal and disgrace.
It should be abolished immediately.
There is no legal or moral bar to such immediate abolition, and such aboli=
tion is amply sustained by precedent.
The responsibility for criminal investigation should be placed completely in
the hands of the district attorneys and the police.
The scandalous jury system and the coroners' court should be entirely
eliminated.
The magisterial functions of the coroner should be entrusted to the
judiciary.
A competent system of medical examination should be established. In
devising such a system no experiment is necessary. The success of the medical
examiner system of Massachusetts is beyond question, and offers a plan upon
which a new system in this city may be erected with every assurance of success.
The new system should be manned by skilled and experienced patholgoists,
the chief of whom should be appointed by the mayor as the result of a nonassembled competitive examination.
Such a system of medical investigation will save the city at least $50,000
a year.
It will insure the termination of the present ignorant, inefficient and even
corrupt performance of the coroners' function, and for the first time in the city's
history, it will invoke in the protection of the community the science of legal
medicine.




REPORT.
THE CORONER'S JURISDICTION.
The law governing the performance of the Coroner's function is contained in a number of statutes enacted at different times and apparently
without regard to their relation to each other; they are replete with redundancies and with real or apparent conflicts.
The Coroner has jurisdiction in all cases where a person dies
(a) " from criminal violence";
(b) "or by a casualty ";
(c) "or suddenly when in apparent health ";
(d) "or when unattended by a physician ";
(e) "or in prison ";
(f) "or in any suspicious or unusual manner."
The Coroner is also given jurisdiction in cases of " dangerous wounding of another" and of suicides. He is further empowered and occasionally
required to perform the ordinary duties of the sheriff in certain proceedings
when the latter is a party therein.
The Coroner's function is to ascertain the cause of death in cases which
come within his jurisdiction. He must determine whether the death was due
to natural causes or to violence. If the former, the specific disease must
be named; if the latter, he must determine whether the violence was accidental, homicidal or suicidal. If homicidal, the Coroner must proceed
further to find who there is reasonable cause to believe guilty of the crime.
In homicidal cases the Coroner must personally " go to the place where
the body of the deceased is and forthwith inquire as to the cause of death
or wrongdoing."
In non-criminal cases the Coroner is required merely to " subpoena one
of the Coroner's physicians who shall view the body."
The Coroner is empowered to direct his physician to make au autopsy
whenever necessary to ascertain the cause of death.
Upon each and every case coming within the Coroner's jurisdiction an
inquest must be held, consisting of the testimony of the Coroner's physician
and of other witnesses and, if there be reason to suspect a crime, a jury must
sit with the Coroner and the findings of his inquest must be filed with the
District Attorney; otherwise the determinations as to the cause of death
are filed with the Health Department as a part of the vital statistics of the
city.
The Coroner has the power to arrest, to hold to bail and in homicidal
cases has all the powers and duties of a magistrate. At his inquests counsel
usually represent the parties in interest and legal questions, particularly




9


on the admissibility of evidence, are often raised, and passed upon by the
Coroner.
IRRESPONSIBILITY.
The exercise of these powers and functions is entrusted to a series of
elective coroners, four in the Borough of Manhattan, two each in the Boroughs of Brooklyn, The Bronx and Queens and one in the Borough of
Richmond. No medical, legal or other qualification is prescribed. To men
without any required special training or ability is entrusted the highly important and difficult duty of protecting the community against the commission of crimes which lead or contribute to manslaughter or murder, and of
collecting a substantial portion of the data upon which our vital statistics
are based.
The law grants to the Coroner very wide powers, while at the same time
making him a relatively obscure public official, subject to no control or restraint except possible removal from office by the governor of the state upon
charges. Such a combination of conditions is almost sure to result in inefficiency and corruption. When indictment and conviction of past coroners
has not prevented recurrence of abuses, removal by the governor is so
much more remote as not to increase any sense of responsibility. Especially
is this so, since no Coroner of this city has ever been removed in this manner.
The irresponsibility of the Coroner's system is further illustrated by the
fact that although Coroners are organized by boards, each one is nevertheless a separate and distinct public official with exactly the same rights and
duties as all his fellows. If he shirks his work or if he abuses the powers
of his office or if he conspires to set guilty defendants free, none of his
fellow coroners has any power to inquire into his acts or to discipline him.
OPPORTUNITIES FOR ABUSE.
When a Coroner has the power to call or omit to call the only witnesses
who might establish strong suspicion of the commission of a crime and when
he can hold his inquest behind closed doors, and thereupon find that the
victim came to his death by natural causes and then file the inquisition papers
in that case with the Health Department instead of with the District Attorney, it is easy to see how the system may be used to conceal rather than to
detect crime. Especially is this so where the case is originally reported to
the Coroner's office alone by a private physician or by an undertaker. Frequently such cases are reported neither to the District Attorney nor to the
police. At other times notification to the police has come days after the deceased was in his grave, and after ample time had elapsed for every witness
or defendant to flee the jurisdiction or to prepare a perjured defense. It is
evident that men of whom no particular qualifications are required will be
more than usually susceptible to the influence of friends and of politics in deciding debatable questions along the lines of their sympathies or interest.




10


The collectibility of life insurance often depends upon the determination
of whether death was suicidal or natural. Accident insurance raises the
question of whether death was accidental or, on the other hand, natural or
suicidal. Liability insurance turns upon the question of negligence on the
part of the insured. While his decisions on these questions are conclusive
on nobody, the Coroner's finding is always influential in shaping the course
of the parties in interest. It has frequently occurred that claims are abandoned, compromised or paid largely by reason of the Coroner's disposition of
the given case. Here is a rich field for this obscure and irresponsible official.
Favoritism and attempted or successful extortion may play a large part.
This inquiry has disclosed several instances where it has. Unquestionably
there have been innumerable others.
Again, the power to order an autopsy becomes an instrument of extortion if the Coroner and his physician wish to force on the family of the deceased a particular undertaker. The threat of sending a body to the morgue
or of performing an unnecessary autopsy is a powerful weapon to induce
compliance with the Coroner's demand that a particular undertaker be engaged or that money be paid. Sitnilarly the power to impose or withhold the
stigma of suicide is effective in prostituting the powers of the office to personal profit.
The tremendous power for abuse inherent in the Coroner's jury system
and instances of its exercise will be detailed hereafter.
With constant temptation and easy opportunity for favoritism and even
extortion, with an utter lack of inspection, supervision or control and without the slightest preparation or training to create in the Coroner's mind a
scientific and professional interest in the performance of his duties, the
present system could not have been better devised intentionally to render
improbable, if not impossible, the honest and efficient performance of the important public function entrusted to his office.
LACK OF TRAINING AND QUALIFICATION.
Of the sixty-five men who have been coroners since consolidation, nineteen were physicians, eight were undertakers, seven were politicians and
chronic office-holders, six were small real estate dealers, two were saloonkeepers and two were plumbers. The remainder constitute a miscellaneous
assortment, comprising a lawyer, a printer, an auctioneer, contractor, carpenter, painter, an expressman, a butcher, wood carver, marble cutter, a
labor leader, an insurance agent, a musician, a milkman, a dentist, and several
whose occupations were unknown.
Of the nineteen physicians elected to the office representing a professional class having more nearly some knowledge to qualify for the office,
not a single one was a man of any standing or reputation in the medical
profession in this city. Generally speaking, they have been doctors chiefly
noted for their political activity.




11
The practice of electing an undertaker has been fraught with great
abuse, for it is against human nature to expect an undertaker who gets to be
a coroner, enjoying the opportunities already mentioned, not to use these
opportunities to increase the income of his private business.
Beyond question a goodly number of the above-mentioned sixty-five
office holders* have been honest and well-meaning men, but not one of them
was adequately qualified for the difficult work either of detecting the clever
commission of murder or, from a scientific point of view, of passing with
adequate intelligence upon the physical cause of death. And few, if any of
them, have been able to preside at any inquest which from a legal viewpoint
was not little short of an absurdity.
CORONER SHOULD NOT BE ELECTIVE.
Unfitness would appear to be inevitable under the elective system applied
to this office.
The Coroner has no questions of public policy to settle. There is no
moot point of interest or importance for him to discuss with the voters. He
is an obscure elective officer. His name appears toward the end of the ballot
already too long for the voter to be in position to give careful consideration
to the merits of all the candidates who appear thereon. Concerning the past
history or present fitness of the candidates for Coroner the great majority
of voters can reasonably be expected to have and usually have no adequate
knowledge and can therefore form no intelligent opinion. The argument,
occasionally advanced at these hearings, that the election of the Coroner is
essential to popular rule does not merit serious consideration. It is but the
survival, along with the elective coroners themselves, of fast disappearing
ignorance, often only feigned, of the fact that effective popular rule lies in
the election, not of a multitude of officials whose claims are known and whose
responsibility runs only to the political "boss," but of a few officials whose
merits can be carefully considered and whose responsibility to the public is
definite, fixed and readily enforceable.
The ordinary candidate for Coroner, moreover, is not nominated
because of assumed fitness to perform his work. He has been nominated
rather to represent a given race, religion, class, political faction or geographical portion of the city. Thus, Coroner Wagner of Brooklyn admitted that
he was nominated " to balance the ticket," and that this was not a satisfactory
way of finding efficient coroners.
Throughout this report will be found illustrations of the medical, legal
or other ignorance of various coroners. As an instance of an absurd medical
conclusion the following will suffice at this time: In the case of William J.
Dinan, who died July 1, 1913, the Coroner held that the deceased came to
his death from "morphine poisoning administered in proper quantities as a
* A table giving the names, occupations and other facts concerning the sixty-five
Coroners since consolidation will be found in Appendix.




12


cure for Bright's disease." Obviously, poisoning cannot result from morphine administered in proper quantities, nor is morphine a cure for Bright's
disease. Coroner Hellenstein, himself a physician, on the stand admitted
that this finding was a "foolish statement" (page 1225, Public hearing
record).
On the legal side no question more frequently arises than the question
of what constitutes criminal negligence and what distinguishes it from simple
negligence. In connection with a case in which Coroner Hellenstein had
charged a jury as to the law on this subject, his charge on the legal side
having obviously been prepared by someone else, I asked him again to define
the law of criminal negligence. After five years' experience as a coroner,
the following definition was the best he could give:
"I would charge the jury if they presumed there was culpable,
that this man was neglectful in bringing about that accident or anything like that, that he would be a criminal negligence."
UNFIT JUDICIAL OFFICER.
In addition to the unfitness produced by lack of training there has been
a further general unfitness of character, demonstrated in part by the fact that
for many years past it has been the general practice of coroners to solicit
employment for friends and political associates from public service corporations.
The Coroner in his official capacity is brought into frequent contact with
such corporations, since the question of possible criminal negligence arises
in many accidents which result in death. It is frequently necessary for such
corporations to give bail for employees charged with criminal negligence.
Fit men for the Coroner's office would, therefore, be exceedingly careful
not to have compromising relations with such corporations.
The fact is, however, as stated, that the compromising relation of constantly soliciting employment is the ordinary relation between the Coroner
and the public service corporation.
On April 20, 1914, one Maurice Cohen pleaded guilty to conducting an
employment agency without a license. It had previously developed that his
method of securing employment for motormen or conductors consisted in
giving to applicants a letter of introduction to a political leader. The
political leader thereupon gave a letter to Coroner Feinberg, who in turn
gave a letter to a street railway corporation.
The charge against Cohen and the hearing upon his arrest received wide
newspaper publicity, yet notwithstanding the abuse shown in this case
Coroner Feinberg, Coroner Hellenstein and employees of the Coroner's
office, notably George Wahl and Louis J. Schwartz, continued to make such
improper requests upon railroad corporations. These letters were not only
written on official paper, but Mr. Wahl took particular pains to sign himself




13


as being of the coroner's staff in the apparent desire to bring forcibly home
to the corporation the advantage of having friends in the Coroner's office.
This matter of letters soliciting employment from large employers of men
who are known to be frequently concerned in coroners' cases, is not confined
to the Manhattan office.
It is only fair to state that some of the public service corporations concerned have shown a higher sense of honor than the Coroner, and have
refused to comply with such requests.
Evidence of a similar unfitness may be found in the fact that Coroner
Hellenstein not only solicited but defended as a means of earning an " honest
dollar," his employment by the Aetna Life Insurance Company of Hartford,
Conn. Insurance companies have an even more constant interest in coroners'
cases than public service corporations. Coroner Hellenstein for months saw
no impropriety in receiving employment as a physician to serve under the
recently enacted Workmen's Compensation Act from an insurance company
which was constantly interested in proceedings before the Coroners' Court.
In this instance, the insurance company, contrary to its practice, as conceded
before me by its representative in charge, employed Coroner Hellenstein
without investigation as to his competence for the work to be entrusted to
him and under an unique arrangement for substitute service by another
physician, named by him and paid by him out of his fees from the company.
The inevitable conclusion is that the company preferred to hire Coroner
Hellenstein rather than to take the chance of offending him. Other companies to whom the Coroner applied for similar employment displayed more
courage and declined his services. That the Coroner was not entirely ignorant
of the vice of this relation with the employing company is shown by the fact
that he testified falsely on this subject until he became aware that all of the
facts were in my possession.
UNFITNESS ADMITTED.
Several of the Coroners now holding office admit the general unfitness
of the elective Coroner, as follows:
Coroner Feinberg" No layman can properly perform the prime function of a
Coroner. The doctor of ordinary household practice is not qualified
for it either; it requires special preparation, special training and
special aptitude. (Page 379.)
" It is a fact that the average lay Coroner is unable to pass intelligently upon the medical work of his Coroner's Physician, or to
pass properly upon the legal questions which arise in connection with
the Coroner's work." (Page 380.)




14


Coroner Healy (Manhattan)" There is no doubt that the present absence of a requirement of
legal training is a serious handicap to a proper performance of the
magisterial functions which are imposed upon a coroner." (Page
1075.)
Coroner Vail"I agree with you that the present coroner's system demands
the combined qualification of medical, legal and judicial knowledge,
and it is therefore unreasonable to expect the average layman to
perform these functions satisfactorily, and there is no doubt in my
mind that a separation of these functions will greatly improve the
conditions as they now exist." (Page 1437.)
Coroner Healy (Bronx)" It is difficult to conceive how it could be reasonably expected
that one man, elected as he is under the present system upon a ballot
all too long for the proper examination of the qualifications of the
candidates by the voters, can be expected in himself to embody all the
technical training that is necessary for the competent discharge of the
medical, the legal and judicial functions imposed upon a coroner.
* * * Certainly it is clear to me that under any adequate system
no layman, however conscientiously he may try and however single
purposed he may be in his devotion to the public's interests, can
administer the office as now constituted with the efficiency which the
important functions of the office call for." (Pages 1422-1424.)
"HORSE SENSE" CORONERS.
On the other hand, Coroner Senior, Coroner Hellenstein and Coroner
Wagner have maintained at different times that nothing in particular is
wrong with the present system. All that a coroner needs, according to them,
is " common sense " or " horse sense." Coroner Senior's testimony is as
follows:
"Q. You do not think there is any fault with the system?
"A. Not properly worked out, no.
"Q. You do not believe that it is burdened by any confusion or
absence of clarity of law in respect to * * * Coroner's office?
"A. No.
" Q. You have not discovered that there is any such?
"A. I haven't found anything that puzzled me but what common sense could get around."
(Page 1404, Public hearing record.)
* * * * * *




15


" Q. It would be your opinion, so far as your experience in office
goes, that previous training of a man is rather immaterial, whether he
is capable to fill the office or not, so long as he is a man of ability
and honest?
"A. I think any man with a good education and with what the
farmers call horse sense can handle the office."
It is worthy of note that in the official acts of the defenders of "common
sense" in cases involving exactly similar questions neither common sense nor
justice seems to require of them action similar to that taken in similar cases.
In reality, the application of the "common sense" so strongly relied upon
means the application of the bias or ignorance of the individual Coroner.
The fact that medical science and legal medicine are sciences at all is
apparently a new idea to these gentlemen. The idea that a criminal investigation must produce evidence which will have a legal value, if it is to be
of any use in criminal prosecution, would also appear to be a startling
thought to our " horse-sense " coroners.
GREATER NEW YORK CORONERS' ASSOCIATION.
Coroner Senior is the President of the Greater New York Coroners'
Association. When a bill to abolish the office was introduced into the
Legislature of 1914 the Coroners seem to have been suddenly struck with
the thought that they should get together and confer as to how they could
become more efficient Coroners; at least such was his idea, Coroner Senior
testifies.
The minutes of the Greater New York Coroners' Association show
that two great subjects were discussed by it. The first was, how could
they prevent themselves from being abolished? It was finally decided
that their course was to be dictated by "the wisdom of waiting until the
advocates of the abolition of the office have used all their ammunition, and
that no statement emanate from the Coroners until a short time before the
adjournment of the Legislature," because it was felt that for the Coroners
to say anything in their own behalf prior to that time " would aggravate and
keep alive the agitation! "
Lest the power of the Greater New York Coroners should not be sufficient to prevent the remedy of the abuses of the Coroner's system, it was
moved at a later meeting that a letter be sent to all the Coroners in the State
inviting their co-operation "to insure uniformity of action and the public
welfare."
In the letter proposed to be sent to brother Coroners throughout the
State occurs this paragraph:
"There is but little room for doubt that such advantagesprivate, public, social, official, educational, and even political-may
be derived from membership in such an organization through an




16


active and co-operative fraternity of interests such as that contemplated, working for the public welfare and exercising a sort of
honorary censorship over the official conduct of its members, while
at the same time steadfastly supporting the principle that 'an injury
to one is the concern of all.'"
Chief Clerk Dalessandro, displaying a high conception of the mutuality
of interest of all concerned, made the proposal that necessary funds should
be raised by assessments upon the salaries of all employees of the Coroners'
office.
The entry in the minutes of the Association is as follows:
" Mr. Dalessandro of the Manhattan office suggests that the required means be realized by an assessment upon the clerks and all
attaches of the various Coroners' offices in the Greater City of New
York, and that an assessment of two dollars upon each one thousand
dollars received in salaries will realize about three hundred dollars;
and asks for the approval of the Coroners' Association of that method
of raising the required means of defraying the necessary expense of
the proposed pamphlet.
" The chair announces, after an expression of opinion by coroners
present, that he sees no objection to the clerks and attaches proceeding as proposed."
The minutes show that Coroner Senior was in the chair on that occasion. This, obviously, is an application of " horse sense " to the financing
of the Coroners' campaign.
The second great question discussed by the Greater New York Coroners' Association was the making of application to the Municipal Civil
Service Commission that Coroners' physicians should no longer be required
to establish even their present mediocre qualifications by competitive examination, but should be placed in the exempt class. Presumably it was felt
that any degree of medical learning on the part of the Coroner's physician
might hinder the exercise of that " horse sense " which is the crowning glory
of the present system. Upon this question, and as illustrating the application of "horse sense" by Coroner Senior himself, his argument on this
question was as follows:
"I think it is to the advantage of the coroners to have this
position placed in the exempt class. I believe it will give more
prestige to the office of coroner. The more important the appointments, the more important the office, and it will given each coroner
an extra appointment.
" If this position is placed in the exempt class I cannot see why
there is any objection to it * * * we have to take from the list




17


any Tom, Dick or Harry, whether we like him or not, and maybe a
man who may be very obnoxious to us, or who may be politically
opposed to us, and not in sympathy with us."
Here we are at last enabled to grasp somewhat more definitely what the
application of " horse sense " to the Coroner's office means. It means, apparently, that the Coroner should seek prestige; it means that a Coroner
should naturally desire to get an extra appointment, if possible; it means
that a little thing like waiving the application of the merit system is something to which "horse sense" can impose no objection; it means that a
doctor, to perform his work efficiently, must be in political sympathy with
the Coroner for whom he works. The one consideration which "horse
sense" seemingly does not include is the efficiency of the Coroner's work.
CORONERS' PHYSICIANS MEDIOCRE.
With few exceptions, including Notably Dr. Otto H. Schultze, the
coroners' physicians are of mediocre capacity, and are not subject to any
adequate control or supervision.
Having slight qualification at the time of their appointment, they have
seldom developed any scientific interest in their work, although it represents
one of the most fertile fields for the extension of accurate medical knowledge.
They are members of no learned bodies devoted to the discussion of the
scientific developments of diagnosis and pathology. They themselves make
no contributions to the development of these sciences. In a few years they
become callous or indifferent to the character of their work. At best, it is
only during their incumbency in office in most instances that they have
through sheer force of repeated contact become acquainted with the rudiments of a science, proficiency in which the public pays for and has a right
to demand and expect of them.
Most of the coroners' physicians are engaged in ordinary medical
practice and many give only so much of their time to their official work as
they consider to be absolutely necessary to hold their positions. Dr. Weston is
employed as an assistant surgeon in the Medical Reserve Corps of the
United States Navy, and is assigned to duty at the Marine Corps Recruiting
Station in this city, the office hours of which are from nine to five, daily.
The spectacle presented by Dr. Weston in the Patrick trial needs only to be
referred to. He emerged from that trial, having taken both sides of the case
at different stages of the proceedings, an utterly discredited witness. Dr.
Weston has often, though not officially on vacation or otherwise relieved
from duty, found it necessary to get a substitute to do a substantial part of
his work as coroner's physician.
In the Borough of Brooklyn a young medical graduate, a man only 27
years of age, has for over a year been doing a large part of the coroners'
physicians' work. He had performed but few autopsies when he took up




18


this work, and without reflecting in the least upon his character, or upon his
potential capacity, he was entirely unfitted at the time to be entrusted with
this most important function. The further fact that on three succeeding days
of a given January, he found four deaths due to valvular heart disease and
four deaths due to acute cardiac dilatation, having made only a superficial
examination in each case, strongly indicates that his findings are not to be
seriously relied upon.
From the frequent admissions of mistakes or of inability to sustain
many of their medical conclusions it must be inferred that the coroner's
physicians, in a large number of cases, jump at their conclusions. They
seldom, if ever, even record the symptoms which would sustain their conclusions. Frequently they have admitted before me that all of the known
symptoms in a case pointed to some cause of death other than the one
given, or to any of several causes of death, and were unable to state what it
was that led them to select one of these causes rather than any of the others.
Generally, the coroners' physicians have a preferred chronic cause of
death. Among these are chronic nephritis, chronic endocarditis and, among
infants, infantile convulsions. When the details surrounding death are
fragmentary, and where there is no clinical history, instead of considering
the need of a most thorough examination the greater, the coroners' physician usually reverts to his routine cause of death. A contest between
chronic nephritis and endocarditis, for example, would be both close and
exciting. This was strikingly illustrated by the case of Elizabeth de
Gincherville, who died February 25, 1914. The death certificate signed by
Coroner's Physician Ray stated the cause of death as chronic nephritis. The
inquisition paper in the same case sets out Dr. Lehane's finding, adopted by
Coroner Hellenstein, that the deceased died of endocarditis. One of the
coroners' physicians had seen the body at the place of death and the other
had seen it at the morgue a day later.
Pressed for an explanation as to why they failed to make a thorough
examination and perform an autopsy when absolutely necessary to establish
the cause of death, Dr. Lehane and others fell back upon the decision in the
case of Hassard vs. Lehane (150 App. Div., 685). That case far from
placing any bar upon a thorough investigation by the coroner's physician,
absolutely upholds the power of the coroner to order an autopsy and to
make a thorough investigation wherever he deems it necessary satisfactorily
to ascertain the cause of death.
SUPERFICIAL EXAMINATION.
The mediocre character of the general work of coroners' physicians
may be explained by the testimony of John Fane, keeper of the Bellevue
morgue:
"Q. What is the longest time that you have seen a coroner's
physician devote to making an examination of a body-not in the
case of an autopsy, but the usual examination?




19


"A. Well, I have seen him take the body and look it all over
from head to foot, put his finger and draw up the eyelids, press the
body at different points, you know. The examination would probably
take, I should judge, about five minutes or a little more.
" Q. That kind of thing is comparatively infrequent?
"A. Oh, no, it is not frequent,
(Page 3695, private hearing record.)
"Q. What is the smallest length of time you have seen devoted
to the examination of a body?
"A. Well, they might just look at the head, that was all.
* * * *     * *
"Q. Does it often happen that they just look at the head?
"A. Well, quite frequently, yes, sir.
(Pages 3690-3691, private hearing record.)
"Q. But there have been some occasions in which he has looked
only at the face and made a certificate?
"A. Yes."
(Page 3689, private hearing record.)
Dr. Guy H. Wallace, Pathologist at Bellevue Hospital, testified as
follows:
" Q. Have you ever seen a coroner's physician make a certificate
of death as to a given body without looking at the body?
"A. I have, as far as I know.
" Q. When was that and who was it?
"A. Dr. Weston.
"When?
"A. I can't fix the time definitely, some time in the early spring
of this year.
"Q. Will you state what you saw on that occasion?
"A. I saw Dr. Weston come into the room at the morgue where
the books are kept, look over the coroners' slips that are made out at
the hospital-that is, the slip giving the clinical history of the case
as ascertained by the hospital * * * read them over, sign the
death certificates and leave the morgue.
"Q. How many of those slips did he read on that occasion?
"A. Six or eight cases."
(Pages 3740-3741, private hearing record.)
Dr. Weston's explanation of this episode-namely, that he had on a
previous visit examined the bodies as to which the certificates were thus
signed, was unconvincing. Even if true it was indicative rather of a different kind of carelessness in view of the pressure of work that he must have
been subject to in attending to his duties as coroner's physician, as naval




20


recruiting surgeon and as private physician and the consequent tax on his
memory as to what he observed or learned with reference to bodies viewed
in an alleged earlier visit to the morgue.
MEDICAL INCAPACITY ADMITTED.
Upon the general capacity of coroners' physicians, Coroner Feinberg
testified as follows:
" It is a fact to-day that the ascertainment of the cause of death
is not efficiently performed in a great number of cases. * * * It
is a fact that the salary paid to the lay-coroners and to unnecessary
subordinates makes it impossible to pay adequate salaries to adequately qualified men, charged with the medical side of the work and
militates against the employment of such men under the present
system."
(Page 380, public hearing record.)
Coroner Wagner testified* as follows:
" The medical examiners who are to conduct the examination
into the physical cause of death should be men of superior qualifications to those occupying the places now and should be obliged to
devote their entire time and attention to the duty of the office to the
exclusion of their private practice, and their salaries should be
sufficient to enable them to sacrifice their private practice to undertake
such public work."
(Page 1335, public hearing record.)
* This testimony is quoted from Coroner Wagner's answer to a specific question.
When Coroner Wagner took the witness stand on December 8, 1914, he had in his
hand a typewritten statement prepared by him in advance, which he proceeded to
read, throwing each page thereof on the table before him as he finished with it. That
statement appears at pages 1311 to 1316 of the record of public hearings. After he
had finished reading the statement, as appears at page 1316 of the record, I asked
the coroner for his typewritten manuscript, stating that some questions were suggested by what he had read. He handed five sheets, constituting the whole manuscript,
to me and then, because he had scattered the sheets before him as he finished with
each, I asked: "You have read this whole thing"' and he answered: "I have read
this whole thing."
Thereafter, under date of December 15, Coroner Wagner requested that two
pages of his typewritten statement be expunged from the record on the ground that
he had not read them. This was declined for the reason apparent from the foregoing, though the coroner's request was also made part of the record.
Among the portions of the statement specifically covered in the question and
answer part of the coroner's examination was the testimony above quoted, the substance of which was also in the disputed part of the formal statement. On these
facts I am led to the conclusion that the reason why the coroner requested the
expunging of this and other portions of the statement part of his testimony was not
because he had not so testified and did not so believe when he appeared before me,
but because he may subsequently for some reason have changed his mind.




21


Coroner Hellenstein testified as follows:
"I do believe that * * * no one physician should be permitted to perform an autopsy, because I don't trust them-two.
" And there should be somebody to take down-  There should
be some man to take right down what was done. I always insist upon
it to be that way; to put that down on paper and not carry it around
in their memory, because some of those physicians are just those who
will switch it over to the side wanted. They are the people who discover " brain storms " and " dementia Americana " from the side
where it comes from. * * *
" Q. That is, you distrust the coroners' physicians when they act
singly?
"A. Yes, I do.
" Q. Upon what do you base that?
" A. I don't pretend to say anything, but you asked me my suggestion "
(Page 1098, Public hearing record.)
NO SUPERVISION OF CORONERS' PHYSICIANS.
The Coroner's physician, far from being subject to any continuous or
effective control, is practically a law unto himself. It is impossible for the
average lay coroner to exercise any such supervision or control, because he
does not possess the knowledge on which alone such supervision could be
based. Neither is he in the habit of compelling his physician to justify his
conclusions. Such disciplinary power as the Manhattan Board of Coroners
possesses over physicians has been used not to improve the character of the
medical work, but rather to harrass and embarrass the most competent of
all their physicians (Dr. Schultze). Despite more serious charges against
other physicians which have been or could have been made, this Board has
seen fit to discipline Dr. Schultze for alleged delay in viewing a body and for
alleged insubordination to the "chief clerk." One is led to the conclusion
that the coroners of the Borough of Manhattan resent the existence of
medical efficiency rather than its opposite.
Dr. Weston has been a coroner's physician in this borough for twentyfive years. His testimony on the character of their medical work and upon
their lack of supervision must be considered authoritative:
"Q. How would you account for your finding that this death
occurred by reason of chronic nephritis and pulmonary edema?
" A. I can't account for it.
" Q. And the death certificate gives it a little bit of a variation
and calls it chronic mephritis and myocarditis; how would you
account for that?
" A. Why, I could account for that very readily.




22


"Q. How?
"A. Somebody has made a mistake.
~^s *   *      *      *     *      *      *      *      *
"Q. Well, now, doctor, there have been several of these mistakes
we have come across.
" A. I have no doubt, Commissioner, that you will find a lot of
mistakes, a great many mistakes.
ss *    *      *      *      *     *      *      *      *
"Q. I ask you if there is not some way that occurs to you of
probably accounting for these mistakes, that is, separate and apart
from any fault that may be personal to you.
"A. You mean some fault of a system under which I work?
"Q. Yes.
"A. Yes.
"Q. Now, what is the fault of that system? What is the answer?
"A. My answer is this: That a great deal of work is crowded
onto a coroner's physician and very little supervision is exercised as
to the character of his work, and he is allowed to do about as he
pleases, and does about as he pleases, with little thorough supervision
of a higher authority to hold him up to the high standard that he
should be held up to. I want to plead guilty and throw myself on
the mercy of the court. If you sentence me to anything less than
death, all right; but the system is lax. It is lax by reason of the want
of central supervision and central responsibility."
(Pages 715-717, Public hearing record.)
EXTORTION.
A serious by-product of this complete lack of supervision is that it
opens the door wide to extortion by coroners' physicians. Since they are not
required to make any adequate record of their findings, nor to justify them
to the coroner, whatever the coroner's physician learns concerning a case he
may retain in his own head. This information he may attempt to sell to an
insurance company or to any one else interested in a case. Similarly, since
his data has not been made a public record, he may refrain from furnishing
any information if his demand for compensation is refused, or again, he may
change his mind and for a consideration become an expert witness for the defense. From the testimony taken in private hearings, I must conclude that
examples of such extortion are not uncommon. Indeed, it appears to be the
policy of some insurance companies carefully to conceal the fact that they
are interested in a death which the coroners' office is investigating, lest they
be subject to demands for money or their interests prejudiced by refusal to
comply with such demands.
In one case, in addition, I cannot escape the conclusion, based upon
corroborated testimony, that Dr. Weston accepted a " present " of $100 from
members of the family of a decedent for refraining from making a postmortem examination. The deceased had been a Christian Scientist, who,




23


for some hours before his death, had received absent treatment, and
for a few minutes prior thereto had had present treatment, from a
Science practitioner.  With no assistance, therefore, from  any clinical
history and upon external examination alone, Dr. Weston certified the cause
of death as valvular cardiac disease. In testifying with reference to this
case, Dr. Weston denied the receipt of the money, but declined to answer
questions as to the furnishings and arrangement of his office, which were
designed to test the accuracy of the testimony given by previous witnesses.
Furthermore, it was admitted by Dr. Weston that he had at the request
of an undertaker, for the purpose of avoiding a coroner's investigation,
" O. K'd " death certificates of other physicians, one of whom, examination
disclosed, had signed such certificate in several cases in which the deceased
had been a Christian Scientist, who had been attended until just before
death by a practitioner of that cult. This Dr. Weston did despite previous
experience with Christian Science cases in which he had found that prompt
medical treatment would probably have saved the life of the deceased. Dr.
Weston volunteered that he " may have borrowed money from undertakers
once in a while."
VITAL STATISTICS.
In the last twenty years great effort has been made by governments, in
co-operation with the best men in the medical profession, to secure vital statistics upon a basis which makes international comparison possible, and
which opens to medical students in each country the vital statistics of every
other. The United States government has entered heartily into this arrangement and the United States Bureau of Census has expended great effort
in trying to shape public health work in accordance with this policy. The
international list has been adopted officially by the Health Department of
The City of New York.
In pursuit of this policy, it becomes of great importance to prevent the
use of indefinite terms when the indefiniteness means simply failure to
analyze intelligently or to diagnose correctly and thus to ascertain the
cause of death accurately. There are certain expressions which are recognized to-day as meaning in effect that the user of them either does not know
the cause of death or is too ignorant or lazy to ascertain it. Among these
causes, which are generally recognized in the profession as being equivalent
either to a guess or to complete ignorance, are the following:
Infantile convulsions,
Acute myocardial insufficiency,
Fatty degeneration of the heart,
Acute cardiac dilatation
Acute endocarditis, 
Marasmus,
Marasmus,.      Unless verified by definite and trustworthy
Ptomaine poisoning,    clinil 
clinical symptoms.
Septicemia
Trismus neonatorum,




24


An examination of the inquisition papers of the Coroners' office shows
that these so-called causes of death are not infrequently used by the
Coroners' physicians, the bracket group on little or no evidence.
Accurate vital statistics are of the utmost importance to a modern
city. They furnish the only possible index to the efficacy of the preventive
measures taken to protect the public health. They furnish the only accurate
basis for ascertaining necessary extensions, curtailments or new activities
in public health protection. The whole campaign against infant mortality,
tuberculosis and venereal diseases has been based on the records of vital
statistics. Progress in the control of communicable disease demands accurate
knowledge of the incidents of the disease, the ages in which it appears and
the habits of life of persons among whom it occurs.
In this connection the following table, prepared by the Health Department, shows the very substantial portion of the city's vital statistics which is
derived from cases passing through the Coroners' office:
TOTAL DEATHS AND STILL BIRTHS REPORTED.
Coroners' Deaths and Still Births.


1910.             1911.           1912.            1913.
Coroners'        Coroners'       Coroners'       Coroners'
Deaths and       Deaths and      Deaths and      Deaths and
Still Births.    Still Births.   Still Births.   Still Births.


ManhattanDeaths......    38,660
Still Births.   3,541
Total....   42,201
BronxDeaths......    6,968
Still Births..    549


Brooklyi
Deal
Still


Total....   7,517
nths......  25,676
Births..   2,221
Total....  27,897


38,386
3,438
5,327  41,824
6,938
579
785   7,517
24,511
2,188
3,178  26,699
3,998
372
701   4,370
1,590
96
227   1,686


36,548
3,311
5,634  39,859
6,944
628
874   7,572
23,994
2,235
3,172  26,229
3,978
374
742   4,352
1,544
71
249   1,615


36,608
3,140
5,489  39,748
7,471
663
900   8,134
23,955
2,286
3,162  26,241
4,229
439
731   4,668
1,639
101
252   1,740


5,645
959


QueensDea
Stil.ths......    3,971
1 Births..     347
Total....    4,318
ndths......     1,467
1 Births..      93
Total....     1,560


3,105
781
310


Richmo:
Dea
Stil


City of New YorkTotal....  83,493


10,218  82,096  10,671  79,627


10,534  80,531  10,800




25


As is generally known, all deaths occurring without the attendance of
a doctor must have the medical cause of death ascertained through the
coroners' office. Among the ignorant portions of our population people die
more or less frequently as a result of virulent or contagious disease. Many
of these diseases cannot be determined without a thorough and highly competent medical inquiry. The failure of the coroners' physicians to make
such inquiry and to determine, for instance, the presence of spinal meningitis, of diphtheria, of scarlet fever or of infantile paralysis deprives the
city of a highly valuable means of preventing the spread of these diseases.
All of the coroners and coroners' physicians who have testified have
been examined upon the relation of their work to the prevention of the
spread of contagious disease and without exception they have manifested
the most utter indifference to any such bearing. Some of them indeed so
treated this subject as to compel the conclusion that the idea that their
work could have any such bearing was a new idea, which they then heard
for the first time.
INQUISITION PAPERS EXAMINED.
This conclusion was sustained by an examination of a large number of
cases upon which the Coroners' Office had acted.
Dr. Haven Emerson, Deputy Commissioner of the Health Department,
himself a physician for fifteen years, at my request examined 800 of the
inquisition papers and their corresponding death certificates filed by the
Manhattan Coroners' Office with the Health Department since January 1,
1914. Dr. Horst Oertel, Pathologist to the Royal Victoria Hospital in
Montreal, lecturer in Pathology in McGill University and a recognized authority upon pathology, also examined similar papers for the year 1913.
Aside from cases in which question as to the exciting cause of injuries was
involved-which question often requires for its determination the conduct
of a judicial inquiry in the interval between the filing of the death certificate
and the filing of inquisition papers-Drs. Emerson and Oertel found many
instances of marked discrepancy between the conclusions stated in the two
documents. Thus:
Mary Downey, died December 9, 1913.
On the death certificate the Coroner's physician certifies that the
cause of death was "valvular heart disease," while on the inquisition paper he testifies, and the coroner finds, the cause of death to
have been " fatty degeneration of the heart." Although these two
causes of death may be associated, there is a marked difference between them.
Pauline Koppleman, died February 20, 1914.
On the death certificate the Coroner's physician certifies that the
cause of death was "chronic endocarditis," and he testified on the




26


inquisition paper, and the coroner found, that the cause of death
was " chronic nephritis." Chronic endocarditis and chronic nephritis
may occur in the same individual, but as causes of death they cannot
be put down as synonymous. It should also be noted in connection
with this case that accompanying the inquisition paper is a report
from a Dr. Dilman stating that the deceased was taken ill with a
severe headache and after taking a household "headache remedy "
had a severe vomiting spell and died two hours later. There is
nothing on the inquisition paper to show that any cognizance was
taken of this fact.
In numerous other cases in which the police had reported pertinent facts,
or in which the deceased had died at a hospital and physicians there in
attendance had recorded their clinical observation of the patient, there was
complete failure on the part of the Coroner's physician to take cognizance of
such reported history in reaching his conclusion as to the cause of death.
Examples follow:
John E. Curtin, died February 7, 1914:
The Coroner's Office sheet setting out the facts received on notification of the case from the police to the Coroner's Office indicates
as the cause of death illuminating gas, and states that the deceased is
said to have committed suicide. In the death certificate the cause of
death is certified as "chronic nephritis and myocarditis." On the
inquisition paper the Coroner's physician testifies and the Coroner
finds, that death was due to "chronic nephritis and pulmonary
oedema." There is no evidence that any investigation was made to
prove or disprove that illuminating gas had anything to do with the
cause of death. Incidentally the causes of death given on the death
certificate and on the inquisition paper, respectively, are not synonymous. The papers disclose, therefore, neither legal sufficiency nor
medical accuracy.
William Holworth, died February 14, 1914:
The police reported that the deceased died as the result of a bullet
wound in his mouth, due to shooting by a Harrington-Richardson
revolver of.38 calibre, and that the revolver containing three loaded
and one exploded cartridges was found clutched in the right hand of
the deceased. On the death certificate the Coroner's physician certifies that the cause of death was due to rupture of a thoracic aneurism,
and on the inquisition paper he testifies to the same cause of death,
and the Coroner so finds. It is inconceivable that a revolver wound
in the mouth could have caused a rupture of the thoracic aneurism.
Charles Hebel, died February 16, 1914.
The cause of death was given by both the Coroner and his physician on the death certificate and on the inquisition as " alcoholism,




27


acute and chronic, and chronic nephritis." The report from the
Knickerbocker Hospital stated that the man died from delirium tremens and was said to have taken two grammes of hydrochloric acid
on the day of his death, and that the immediate cause of death was
oedema of the brain. Here is a suspicious circumstance preceding
death to which no regard was paid so far as the record discloses.
Heinrick Freedman, died February 7, 1914.
Both the Coroner and his physician, on the death certificate and
on the inquisition paper, certify that death was due to "chronic
nephritis." No autopsy was made and there is no evidence attached
to the papers on which to base such a finding. There is annexed to
the papers a report from the 39th Police Precinct and also a report
from a physician of the Reception Hospital, both stating the cause of
death to be " illuminating gas, accidental." The papers disclose no
investigation of this report that death was due to illuminating gas.
In 320 cases, or 40 per cent. of those examined, Dr. Emerson found a
complete lack of evidence in the official papers to justify the cause of death
certified, unless there was some evidence of clinical value, which nowhere
appeared in the papers.
Quotation has already been made from the record upon the matter of
the utter carelessness of the work of Coroners' physicians. In the connection specifically under consideration at this point, it is illuminating to
examine the case of Lena Garfinkle, who died at the Beth Israel Hospital on
March 11, 1914. Calling at the hospital, which had reported the case to
the Coroners' office by reason of inability to ascribe the cause of death, Dr.
Lehane became impatient at the delay of the house physician who had
knowledge of the case, in joining him, and went to the hospital morgue
accompanied by a clerk who knew nothing about the case. There Dr.
Lehane spent a minute in looking at the face of the deceased and without the
slightest additional examination and with no history, certified the cause of
death as endocarditis. The facts, which Dr. Lehane made no effort to
obtain, were that the deceased had called at the hospital dispensary, was
thence referred to the hospital for X-ray examination to ascertain whether
or not she was suffering from pericolic adhesions, had been given a bismuth
enema and died a few minutes thereafter.
The conclusion is inevitable that the more than ten per cent. of the city's
cause of death statistics which emanate from the Coroners' office abounds
with error and is grossly misleading.
Officials of the Health Department have testified that they have made
for many years constant and earnest effort to bring the medical work of the
Coroners' physicians up to a reasonable standard. They have testified
further that these efforts have been practically fruitless. It appears upon
the record of the inquiry that the Health Department in despair has been




28


finally forced into a position where it accepts from Coroners' physicians inaccurate or insufficient certificates which it would not accept from physicians
in private practice.
The fact therefore is that the city's vital statistics would be far more
accurate if the Coroners' physicians' certificates were entirely excluded. It
is, however, obviously impossible to exclude these certificates because they
cover some of the most important and some of the most controllable causes
of death. Therefore among the many other dis-services which the present
system renders must be included this impairment of the value and accuracy
of the city's vital statistics.
By law, the coroner is responsible for the death certificate of his
Coroner's physician. Considerable supervision could be exercised by competent men if they compelled their physicians to justify their medical conclusions before attaching their signatures as Coroners. But far from exercising any such control death certificates are signed in advance, and quite
often with the stamped signature of the Coroner.
INADEQUATE MEDICAL EXAMINATION IN CRIMINAL CASES.
It may be said that the function of the Coroners' system is primarily on
the side of criminal deaths and that, therefore, its complete failure as an
adjunct of the Health Department is not important. Upon this assumption
one might reasonably expect a fair degree of efficiency to characterize the
work of the Coroners' physicians in the field of medical examination of cases
involving possible crime. Such expectation is not fulfilled. The same
mediocrity, laxity and general indifference to merit which was found in
cases of natural cause deaths and suicides obtains in cases of deaths which
fairly involve the question of possible crime.
The task of distinguishing between homicidal, suicidal and accidental
deaths is often difficult and calls for the very highest degree of proficiency.
Thus, in one case that has been examined (Eugene Rochette; died
March 9, 1914), there was serious question as to whether a bullet wound of
the brain, which the Coroner's physician upon mere external examination
found to be suicidal, was not, in fact, homicidal. Capable pathologists who
also saw the body were inclined to the opinion that it was, and emphasized
the necessity of autopsy, competently performed, to decide the question in
such cases. That case well illustrates the importance of expert medical examination where the first or only clue to crime must be obtained as the result of
such examination. The same thing was further illustrated by another case
(Charles Ingram; died January 23, 1909), in which a post-mortem examination by outside physicians revealed a fracture of the Back of the skull, though
there was no abrasion of the scalp visible by external examination. The injury had been inflicted probably by a sand bag or other soft implement which
fractures the skull without cutting the scalp. The cases cited, counterparts
of which frequently occur, suffice to show that even when violence is in



29


volved it requires no small ability to determine by medical examination
whether or not crime is to be suspected and further investigation made.
When the more subtle forms of homicide are in question, the most
skillful application of modern science is essential. Thus it is a well
known fact that there are a number of fatal poisons which produce convulsions in infants, and their symptoms are not easily distinguishable from
the symptoms of certain natural causes of death. Again, the effects of
irritant poisons simulate the symptoms of cholera. Strychnine poisoning
often simulates tetanus. Accordingly cases of infantile convulsions, cases
of alleged acute gastro-enteritis, and those of alleged ptomaine poisoning,
as well as those summarily disposed of as still births, premature births,
atalectacis pulmonum, and trismus neonatorum, cannot uniformly be safely
assumed to be due to natural causes.
UNDETECTED CRIME.
The usual failure of the coroners' physicians to make or seek direction
to make autopsies or chemical analysis of certain organs in such cases, and
their well-nigh uniform practice of reaching, upon mere examination without satisfactory clinical history, the conclusion that, in nearly all of many
cases of these kinds, death was due to natural causes, must be regarded
inevitably as having all too often failed to disclose cases of homicide.
Upon this subject Dr. James Ewing, professor of pathology in Cornell
University Medical College, and a recognized authority in this field, testified that he questioned the accuracy of the Manhattan coroners' finding of
but one infanticide in the year 1913 in the face of their finding of a large
number of cases of alleged still birth and premature birth, in which no post
mortem examinations were made. Further, pointing out that " infantile convulsions," which so often appears as the cause of death certified by coroners'
physicians upon examination alone, is but a symptom often associated with
death by asphyxia, by acute infectious disease or by poisoning by convulsive drugs such as strychnine, he stated that he considered infanticide a distinct possibility in many of these cases. Without going into the further
details of Professor Ewing's testimony, the following may be quoted:
" I should say that as far as the activities of the coroners' office,
as you have detailed them to me, are concerned, that infanticide
would be carried on with impunity in New York City."
(Page 215, Record of public hearings.)
I find, also, that the facts generally warrant this further statement of
Professor Ewing:
"I feel that New York gets along practically without any aid
from the science of legal medicine ** * * I may say further that my
views, as I believe, are shared by my colleagues in pathology, not




30


only in this city but in other cities in this country and in other countries of the world."
(Page 223, Record of public hearings.)
INADEQUATE CHEMICAL EXAMINATION.
Mr. James P. Atkinson, Chief Chemist of the Health Department, was
also a witness before me. He testified that for a number of years his laboratory had made chemical analyses for the police and for various coroners'
physicians; that seldom, if ever, did a coroner's physician bring to him for
such analysis all of the requisite and necessary material by which there
could be adequately proved that one or another form of any poisoning was
the cause of death. He testified further that there is a complete absence of
any system of uniform receptacles for preserving analyzed portions of the
human body, which in cases of alleged homicide would be evidence of the
highest importance. The failure to prepare in addition a complete and
accurate system of registration and identification tended to throw question
upon whether or not the specimen submitted in any given trial was taken
from the body of the victim of the alleged murderer.
This question has an important bearing upon the financial cost to the
community of its machinery for detecting, preventing and punishing crime.
The failure in a single instance adequately to handle the matter of chemical
analysis may involve the City in very extraordinary expenditures in the later
process of a criminal trial. For instance, in the famous Patrick trial The
City of New York had to pay over $18,000 for expert chemical work, a
considerable portion, if not all, of which would have been avoided had the
coroners' system in the first place been manned by competent analysts.
SUSPICIOUS CIRCUMSTANCES IGNORED.
Without attempting to suggest, far less to express the conclusion, that
crime actually was involved therein, reference may here be made to the
complete absence of medical investigation in the case of Charles Lips, already mentioned, and to the case of Anna Marzo, who died February 2,
1909. In the case last named, a private physician, who was called, learned
that the deceased had been taken violently ill and vomited several times
after drinking coffee. The physician found the heart and lungs normal
and temperature normal, and concluded that his patient was suffering from
an upset stomach, prescribing some simple remedy therefor. Early the
following morning the physician was again called and found his patient
dead. His investigation developed that death had followed the drinking of
some more coffee which had been prepared for her. Thereupon he reported
the case to the Coroner's office. Though an undertaker urged the physician
to sign the death certificate, he refused. Then some one representing himself over the telephone as the Coroner's physician in charge of the case,




31


also urged the physician to make the death certificate. He again refused,
stating that he had never seen anybody die so fast and that he believed the
case merited careful investigation, including autopsy. The record shows,
however, that, on the contrary, the case was disposed of by Coroner's Physician O'Hanlon on examination as death caused by hemorrhage pulmonum.
The private physician in the case, upon his examination of the living patient
and of her body and the surroundings shortly after death, had found no
indication of any lung hemorrhage.
Certainly in the case cited there would appear to have been no official
examination on the medical side sufficient reasonably to preclude the attending physician's suspicion that the deceased had been the victim of
poison. Moreover, the case well illustrates how completely unfounded in
many instances must be the explanation so often offered in this inquiry by
coroners and their physicians for the absence of complete medical examination, namely, that a satisfactory clinical history, unrecorded in the official
papers, had been received from an attending physician who, merely from
excess of caution, had brought the case to the Coroner's attention.
DEFECTIVE IDENTIFICATION.
It is an important element of the function of the Coroner's physician,
on the criminal side, to make certain of the identification of the body which
he views. Proof of the corpus delicti is, of course, essential to the maintenance of a successful criminal prosecution. Here, too, the Coroners'
physicians are not to be relied upon. Thus, in the case of Samuel Garrett,
who died in Bellevue Hospital on February 10, 1914, the Coroner's physician,
in this instance the Manhattan unofficial substitute Coroner's physician,
autopsied the body and found the cause of death to be fracture of the skull
by a blow of some instrument, probably a blackjack. This conclusion apparently showed that the physician was of the opinion that the deceased
had been assaulted and had died as the result of the assault. The autopsy
had, however, been made without proper identification of the body, the inquisition papers being endorsed " identified by hospital records." At the trial
of the defendant the proof of the corpus delicti was very difficult, the District Attorney being compelled to call as witnesses in proof thereof every
person who had anything to do with the deceased from the time he was
assaulted up to the time of his burial.
In this connection, too, it should be mentioned that at least one Coroner's physician, Dr. Lehane, who has been in the service for many years,
testified that he did not consider it any part of his function, in first instance,
to detect crime by medical examination. He should be expected to go no
further, he thought, than to investigate the validity of information as to
crime brought to him from extraneous sources.
Altogether, I have reached the conclusion that with few exceptions the
work of the Coroner's physicians in this city in the field of criminal deaths
is little, if any, better than in that of natural cause deaths.




32
THE CORONERS' JURY.
Defective as the coroners' system is in other aspects, nowhere have its
shortcomings, its temptations to maladministration and its positive working
of evil, more clearly been manifested than in connection with coroners'
juries. As if intended deliberately to invite favoritism and corruption, the
law defining the cases in which juries shall sit with the Coroner upon inquests carries upon its face an apparent conflict which lends itself readily
either through the Coroner's ignorance or worse, to the dispensing with
juries whenever that course seems best adapted to the accomplishment of a
desired result. The so-called Consolidation Act (Laws of 1882, chapter 410)
makes the calling of juries in coroners' cases optional with the Coroner,
except upon the demand of a citizen, providing (section 1774) that " should
the Coroner deem it necessary, he may call a jury to assist him in his investigation."
The Code of Criminal Procedure, on the other hand, in section 773,
makes it mandatory upon the Coroner in this city to summon a jury to sit
with him whenever he " is informed that a person has been killed or dangerously wounded by another, or has suddenly died under such circumstances
as to afford a reasonable ground to suspect that his death has been occasioned
by the act of another by criminal means, or has committed suicide."
A VICIOUS SYSTEM.
As matter of legal interpretation, it would seem clear that this apparent
conflict is to be resolved upon the principle that the mandatory provision
applies to all cases covered by the Criminal Code-that is, briefly, wherever
there is reasonable ground to suspect that a crime has been committedand that the provision of the Consolidation Act applies to other cases within
the Coroner's jurisdiction. The apparent conflict, however, has often been
seized upon when a coroner has found it necessary to explain his failure to
call a jury in a case his conduct of which was otherwise fairly subject to
suspicion. In such instances the Coroner has usually pleaded ignorance of
the interpretation which reconciles the apparently conflicting statutory provisions.
As if the difference in the two provisions of law just mentioned were not
sufficient to afford opportunity for and to tempt misfeasance, there is,
further, an entire lack of prescribed legal method for ensuring, when juries
are summoned, that the members thereof shall be unbiased, disinterested and
otherwise fair and impartial. Thus the Consolidation Act (section 1774)
provides that "any citizen of this state not over seventy years of age, and
being at the time a resident of the county, may be summoned to serve as a
juror upon a coroner's inquest." The Criminal Code (section 773) imposes
in effect the additional requirements that jurors must have the usual property
qualifications, must be in possession of their natural faculties, not infirm or
decrepid, and free from all legal exceptions, intelligent, of good character,




33


and able to read and write the English language understandingly. In practice, however, when jurors are summoned, the provisions of the Consolidation Act only is applied. In no event does the Commissioner of Jurors or
any other outside agency of government performing the same function,
intervene. The result has been that coroners' juries have not infrequently
numbered among their members non-residents, aliens, illiterates, persons
who could not understand English, and, worse than all, friends and persons
otherwise interested in the specific defendant under arrest before the
Coroner at the inquest upon which such jurors have sat. Parties in interest
have no legal right to challenge a coroner's juror. The responsibility upon
the Coroner is, accordingly, the greater, but this responsibility he has in
many instances been unworthy of having entrusted to him.
SELECTION OF JURORS.
In Manhattan, the practice is said to be that the jurors who shall sit
upon a given case are chosen by the selection of names that appear upon
shop windows, or in the various directories, and that then the persons so
chosen are served with a jury summons by the private clerk of the Coroner.
A more frequent procedure, however, is to have the political friends or associates of the Coroner and his clerk act as jurors. When formal notice to sit
as a juror is given an outside person such notice is either mailed or personally
served, seldom by the coroner's clerk, and usually by some unofficially
attached individual who is paid by the clerk a nominal fee for his labor. It
was also the practice in Manhattan up to a very recent date, and it may still
persist, to call the jurors who are to sit with a given coroner from the district
whence the presiding coroner comes. Altogether the coroner's jury furnishes
a tempting opportunity and an easy means of impeding the administration of
criminal justice, and of prejudicing the civil rights of interested parties by
the simple process of packing a coroner's jury.
Moreover, it has been testified by the clerk of a former coroner, that
under the procedure then and still in vogue in Manhattan, it would be perfectly simple for a friend of a party interested in an inquest to present
himself as a juror, though not summoned, and to serve as such either with
or without the connivance of the Coroner. One case has, also, been brought
to my attention wherein there is ground for belief that a relative of the
wife of the accused served as a juror and signed a false name to the inquisition paper. The defendant in that case was released by the jury's verdict,
but was subsequently indicted and convicted.
PETTY GRAFT.
It was also testified that the summoning of coroner's jurors has been
made a means of petty graft by various members of the coroner's office.
The person who summoned a juror assumed the power to excuse him, and




34
this power was also assumed by various members of the office staff. No
fees are paid to coroner's jurors, and the power to excuse from this onerous
duty has been used both to give the person exercising it political prestige and
as a means of extortion. The ex-coroner's secretary testified that he had
more than once been offered a dollar to excuse a juror but had refused it;
that while he had seen no money handed to the other coroner's clerks, it
was common knowledge in the office that this practice was going on; that he
had notified his coroner of it without result, and that it was a standing joke
that one of the secretaries would take as low as a quarter from jurors who
desired to be excused.
THE SYSTEM IN OPERATION.
Following are instances showing how simple it is for a coroner to disregard the statutory mandate that a jury be called:
In the case of Robert Dooley, who died on January 10, 1910, at the
Harlem Hospital, from the effects of a bullet wound inflicted by William
Heineman on the evening of January 1, 1910, though the case was clearly
one which came within the mandatory requirements of a jury provided for
in the Criminal Code, Coroner Feinberg, who presided, held the inquest in
his private office and did not call a jury. This was not the least of several
questionable circumstances incident to the conduct of this case (including
the failure to call known witnesses) as the result of which the defendant
was discharged by the Coroner on the ground that he was justified in shooting the deceased. He was afterwards indicted by the grand jury, and convicted of manslaughter in the first degree, which conviction the Court of
Appeals reversed largely on the ground that the trial court had erroneously
excluded from the consideration of the jury the possibility of conviction for
manslaughter in the second degree. The case is now awaiting retrial. The
Coroner, when examined in this investigation, pleaded, but did not establish
satisfactorily to my mind, ignorance of the identity and whereabouts of the
uncalled witnesses, and ignorance at the time when this case arose, but since
overcome, that the mandatory provision for the calling of a jury applied.
So again in the case of Rev. James Ross, who died on November 18,
1913, as the result of being struck by an automobile, Coroner Hellenstein,
who presided at the inquest, among other revolting features of the handling
of this case, omitted to call a jury, though he had previously shown by his
testimony a correct understanding of the law governing the matter of calling
juries, and had, indeed, cited cases of death by casualty as typical instances
in which it was mandatory to have a jury at the inquest for the purpose of
passing upon possible questions of criminal negligence. This case will be
referred to again hereafter.
The evils of the coroners' jury system are nowhere better illustrated
than in connection with deaths from criminal operations to be hereafter discussed. In those cases, where juries are called at all, it is not unusual when




35


physicians are defendants, to have other physicians serve as jurors. Obviously the result must be, as it has been, that a feeling of comradeship with
the defendant, recollection of instances where suspicion was or might have
been directed against the physician jurors themselves and hypercritical
examination of medical evidence, all combine to induce a finding that the
defendant is blameless.
CORONERS' JURY SHOULD BE ELIMINATED.
Even though there were no confusion in the law governing the calling of
juries, and even though, when called, jurors were chosen with the safeguards for ensuring the calling of properly qualified disinterested and unbiased persons, such as obtain in the selection of trial jurors, it would still
be a fact that the preliminary investigation into sudden deaths for the
purpose of ascertaining whether there is reasonable cause to believe anybody
criminally responsible therefor, is no proper field for the intervention of a
jury.
In olden times in rural communities, when sudden deaths were comparatively infrequent, and when the system of lay coroners originated, it might
well be that thirteen heads could be considered better than one in arriving
at conclusions as to what and who had been the cause of a given death. In
modern times, however, and in the conditions of New York City life and
death, the jury has no legitimate part in connection with the coroner's
inquest. It serves only to divide responsibility with the Coroner for the
efficiency, accuracy and honesty of his work. In his preliminary judicial
investigation into a death, the Coroner performs precisely the same function
as does the committing magistrate in an investigation of other crimes. Just
as there is no necessity for and every argument against having juries in the
magistrates' courts, so they are unnecessary and merely mischievous in connection with investigations of sudden deaths.
While the Chief Clerk of the Manhattan office has repeatedly gone so
far as to recommend reform in the method of selecting jurors, several
Coroners have in their testimony before me expressed the opinion that juries
should be entirely eliminated from participation in determining the cause and
responsibility for death. Thus:
Coroner Feinberg, of Manhattan, stated (Record public hearings, p.
380):
" It is a fact that the jury system in the Coroner's Court is obsolete, practically useless, and subject to great possible abuse under given
conditions."
Coroner Wagner, of Brooklyn, testified (Record public hearings, p.
1315):
" In so far as the Coroner's jury is concerned, I find that its only
use is to assist the conscience of the Coroner. In most cases it is




36


entirely unnecessary and an economic waste, and can be easily dispensed with."
He further stated that having a jury would enable an unscrupulous
Coroner to evade responsibility for the action taken.
Coroner Vail, of Richmond, expressed himself as follows (Record
public hearings, p. 1437):
" Regarding the present jury system, when one considers the
great difficulties experienced by the Coroner's Office in obtaining
reputable and efficient jurors because of non-compensation for services
and the limited powers of the Coroner regarding punishment of
jurors who fail to respond to a summons I have never been able to
see the necessity for same. And also by reason of the divided
responsibility it is possible for a corrupt Coroner to prostitute the
powers of his office if he is so inclined."
Coroner Healy, of The Bronx, stated (Record public hearings, p. 1425):
"To my mind also, the jury system in the Coroner's Court is
obsolete. City Magistrates who, like the Coroners, are in cases of
felony vested only with the power to determine whether there is probable cause to believe a defendant guilty of the crime, and who are, as
are the Coroners, not empowered to pass final judgment, do not have
juries, and the system of our magistrates has never been criticised by
reason of the absence of juries. Indeed, the elimination of the jury
tends to concentrate responsibility where it belongs. Moreover, I
can well see how, with a jury to divide responsibility with him, an
unscrupulous individual holding the office of Coroner might, especially
in view of the absence of provisions governing the selection of the
jury, use the jury for purposes contrary to law and the proper
administration of justice."
WHOLLY INADEQUATE RECORDS.
The defective medical and legal work shown by tie elective Coroners'
system is inevitable; but the evils arising therefrom have been greatly augmented by the complete failure to realize the value of adequate records.
The records kept by the Coroners are as meagre and uninforming as
could possibly be. The vast majority of inquisition papers consist simply
of the sworn statement that the Coroner's physician has viewed the body of
some deceased person, and upon examination has arrived at the conclusion
that the said person died from the cause which he mentions. This conclusion the Coroner authenticates by signing his name to a repetition of the
physician's statement. Nothing is recorded as to any of the external signs
which would at least tend to support the finding. Even when the cause of
death cannot be ascertained without autopsy, and one is performed, there is




37


no adequate record of the findings on post mortem examination. In the
great proportion of such cases the inquisition paper consists simply of the
sworn statement of the Coroner's physician that he has performed an
autopsy, and that he believes the cause of death to be that which he mentions.
Details, if recorded at all, are scribbled down by the Coroner's physician in
a note book which is a merely private memorandum. Occasionally, but only
occasionally, an absurd makeshift for what scientists know as a protocol
appears on the inquisition papers.
It therefore not infrequently occurs that the Coroner's physician testifies
in cases of murder and manslaughter from mere memory. The hideousness
of such a situation is equally great, whether looked at from the point of
view of the defendant on trial or from the point of view of efficient criminal
prosecution.
In cases of suspected crime, the Coroner himself is required to call all
obtainable witnesses who can throw light on how the particular deceased
person came to his death. Usually it does not appear upon the record,
except where there was a jury and testimony taken, whether or not the
Coroner ever called these witnesses or they ever testified. On the other
hand, it often appears that there are instances in which known witnesses
were not called.
This complete failure to keep adequate records facilitates the suppression of evidence and the successful conclusion of conspiracies to impede
justice, and to deprive District Attorneys of material to assist in later criminal prosecution.
RECORDS WITHHELD FROM DISTRICT ATTORNEY.
As though this were not sufficient, the Coroners have been guilty of
extended failure to file any papers with the District Attorney at all. The
law requires that the papers in all cases of possible or suspected crime
should be filed with the District Attorney forthwith. The evident intention
of this law is to furnish the District Attorney with early notice of any facts
in the Coroner's possession for use in developing a criminal investigation,
and of bringing to trial the persons believed to be guilty of the crimes in
question. After this investigation was under way, the Board of Coroners of
the Borough of Manhattan filed for the first time with the District Attorney
of this county the inquisition papers in 431 cases of possible criminality. The
District Attorney's office had been unaware of the existence of 323 of these
cases, 63 of which were over three years old, and nearly 200 of which were
over one year old. A table of these cases follows:




38


TABLE OF CASES IN WHICH MANHATTAN CORONERS' OFFICE DELAYED FIVE DAYS OR
MORE IN TRANSMITTING INQUISITION PAPERS TO NEW YORK COUNTY DISTRICT
ATTORNEY'S OFFICE.
(Figures in parenthesis indicate the number of these cases of which the District
Attorney had no previous notice from any source.)


-0.
rd
O 
tO.,.
5 to 10 days, inclusive......
11 days to 1 mo., inclusive...........  4  (1)
1 mo. to 2 mos., inclusive...........  10 (7)
2 mos. to 4 mos., inclusive...........  12  (9)
4 mos. to 6 mos., inclusive.................
6 mos. to 1 yr., inclusive.................
1 yr. to 1 /2 yr., inclusive................
1 2 yr. to 2 yrs., inclusive.................
2 yrs. to 2/2 yrs., inclusive.................
2V2 yrs. to 3 yrs., inclusive.................
Over  3  years..............
26 (17)


0U
1 (
17 (11)
19 (14)


c
o U
-(3
6 (3)
14 (13)


o 2
0.
0 <U
1(1)
22 (18)


o
0 4-            c
ou 
0         0          0.............  24  (15)............  59  (46).............  55  (37)............  13  (10).............   2 (1)


11(7)    14 (9)   20 (14)............    1(1)............    2   (1)........................... 15 (13)  15 (13)........................... 32 (28)  32 (28)...........................41 (29)  41(29)...................     1 (1)   67(56)    68(57)


47 (32)


13
35 (25)


46 (35)...... 59 (43)  59 (43)
5 (1)  57 (43)  63 (44)
6 (2) 271(212)431(323)


DISTRICT ATTORNEYS ESTABLISH HOMICIDE BUREAUS.
In view of the foregoing, it is not to be wondered that the District Attorneys of New York and Kings counties have taken other steps to assist
them adequately to prepare cases for criminal prosecution. On January 1,
1906, the homicide bureau of the New York District Attorney's office was
organized on a night and day basis, and thereafter undertook the complete
investigation of homicide cases from beginning to end. On June 1, 1912,
the homicide bureau of the Kings County District Attorney's office was
similarly organized; and on January 1, 1914, the District Attorney of the
newly created Bronx County followed suit. By a rule of the police department, notifications of homicides are sent to the District Attorney of the
county in question simultaneously with the sending of the information to the
Coroner's office.
These homicide bureaus make a complete and independent criminal investigation. Members of the staffs of such bureaus have testified that the
Coroner renders no substantial assistance in this work, and that they pay
practically no attention to the Coroner's findings and conclusions. Thus the




39


homicide bureau is a second piece of machinery for performing the function
which by law is entrusted to the Coroner. The existence of these bureaus
and the steps which they take to make an immediate and independent investigation of all possible homicides is in effect a demonstration of the incapacity
and inefficiency of the Coroner's system. The public is called upon to pay
the expense of two organizations, one of which actually does the work which
the other is supposed to do.
The organization of homicide bureaus by the various District Attorneys
is highly to be commended. They were urgently required if efficient criminal
investigations were to be promptly begun. They were more than justified
also in order to insure that criminal cases should not be lost due to the
bungling methods employed by many Coroners. What happened under
other conditions may well be illustrated by the case of People vs. Deiso.
Concerning this case, Deputy Assistant District Attorney Skinner testified
as follows:
" That is an automobile case in which two automobiles were racing south on White Plains avenue about nine o'clock in the evening,
last October I think it was, and one of them became unmanageable
for some reason or other and went upon the sidewalk on 225th street
and killed a child; and jumped across the street and killed a man on
the opposite corner, and then went down in a lot. The automobile
should have been left there and not touched and a number of policemen put around it so that no one could touch it until the next day
when it should have been photographed and examined by experts
before it had been touched by anybody. Instead of that, the Coroner
in the fullness of his wisdom had it moved and by reason of that fact
we lost the case." (Record of Private Hearings, p. 1288.)
President Feinberg, of the Manhattan Board of Coroners, testified on
this point as follows:
" It is a fact that various District Attorneys have felt it incumbent
in criminal cases to duplicate to a greater or lesser extent the work
of the Coroner's office. I believe that this duplication of work by
District Attorneys has been due to their conviction, not unfounded,
that the present Coroners' system is inadequate." (Record of Public
Hearings, p. 381.)
THE ABORTION SCANDAL.
The simplicity and ease with which the Coroners' system lends itself
to favoritism, corruption and laxity, and the almost incredible ignorance of
the men who can be elected to office under it, are nowhere better exhibited
than by the results of an examination into a group of cases involving death
following criminal abortion operations. In none of the cases to be cited can




40


it be said definitely that the physician or midwife concerned was actually
guilty of crime. Nor is such a finding necessary for present purposes. All
that is necessary is the conviction, which appears to me to be inevitable from
the facts, that the Coroners' proceedings were not such as reasonably to
prevent the escape of the guilty party, if any there was. In none of the
cases to be cited have I had direct proof of the passing of money to anybody
in the Coroners' office. At least in one of the cases, the Coroner's scandalous
action is explainable on the ground of his friendship with the defendant. As
to other cases, the conduct of the office can only have been due either to
outrageous stupidity or to cash payment to some one.
In view of the facts disclosed, it is not easy to discredit statements which
have repeatedly been made to me to the effect that for many years there has
been in this city a so-called " abortion trust," with a specific point of contact
with the Coroners' office in one individual, a physician, known as the
"Abortion Commissioner," who himself undertakes the performance of
criminal operations, and who, moreover, obtains immunity from prosecution
by the Coroners' office for his colleagues, when they are in danger of such
prosecution. The cases to be examined show how readily discharge can be
obtained in the Coroners' office when the commission of criminal operation
is established at least sufficiently for consideration by the Grand Jury. How
much easier it must be when the rigging is begun, as readily it can be, at an
earlier stage, so that a case of peritonitis from criminal operation is reported
to and accepted and treated by the Coroners' office as one of gastritis or
other ordinary disease.
So far as the matter of juries is concerned, two methods appear to be
followed. Either the mandatory provision of law requiring the presence of
a jury is flouted and none is called, or the record upon its face is kept clear
by the calling of a jury, and then the simple expedient is followed of packing
the jury. Though the cases cited have to do with the administration of a
single Coroner, it has developed that counterparts of his conduct in most
instances is to be found elsewhere in the Coroners' office.
THE CASE OF A CORONER'S FRIEND.
In the case of Josephine Taus, who died January 31, 1913 the physician
who was arrested upon the charge of having performed a criminal abortion, which resulted in the death of the deceased, was a friend of sixteen
years' standing of Coroner Hellenstein. They had both been members of
a physicians' association on the lower East Side, where the relations of the
members to each other were, as the physician testified, "like one family."
The physician and the Coroner knew each other so intimately that they
called each other by nicknames.
The complaint against the physician was made by a member of the
family of the deceased to the District Attorney, who reported the case to
the police, who in turn reported it to the Coroner's office. Under the de



41


cisions, Coroner Hellenstein sat upon the case as a magistrate or judicial
officer.
From the evidence before me it appears that before the complaint had
reached the Coroner's office, but in the expectation that one would be made,
the physician in question immediately got in touch with Coroner Hellenstein, told him that he was in trouble, that the case would probably be reported to the Coroner's office, and requested him to "do something for
him." To this the Coroner replied that he would do his best, stating at the
same time that if the complaint materialized the physician would have to
give bail. Next day, February 1st, the case officially reached the Coroner's
office by notification from a police detective and Coroner Hellenstein telephoned to the physician telling him to surrender himself at the Coroner's
house and to produce a bondsman at the same time and give bail. The
physician complied and produced as his bondsman the wife of another physician who also was a member of the physicians' club referred to. The
written portion of the body of the bail bond is in the handwriting of
Coroner Hellenstein's secretary, Mr. Louis Schwartz, an attorney, but the
bond as executed was at least of doubtful legal efficacy, by reason of the
omission of the Coroner's signature both to the acknowledgment and to the
affidavit of qualification by the bondsman.
THE CASE "SWITCHED."
The case had been reported to the Coroner's office at 11:41 A. M.,
which was in the "tour" of Coroner Holtzhauser. The entry in the daybook of the Coroner's office states that " Hellenstein took case." This was
a departure from the usual routine of the Manhattan Coroner's office, under
which each Coroner takes exclusive jurisdiction of the cases reported to
the office during the hours of the day, called his "tour," during which he
was assigned to duty. Coroner Hellenstein's tour did not begin until 1
P. M. on this date. Mr. Wahl, the clerk who made the entry of the transfer
of the case to Coroner Hellenstein, explained the transfer on the ground
that it was not unusual to switch abortion cases to the Coroners who were
physicians. This explanation was rejected by Coroner Hellenstein in his
testimony before me, and must be rejected, since the daybook shows numerous other cases of abortion which were not taken from the lay Coroners
during whose tours they were reported. Coroner Hellenstein's explanation
of the switching of the case to him is that it was due to the fact that Coroner Holtzhauser, though on duty at the time, could not be reached. This
explanation, likewise, is unconvincing, and the conclusion compelled from
the circumstances of the case-including the testimony of the defendant
physician that Coroner Hellenstein told him that he, Hellenstein, had arranged with Coroner Holtzhauser for the transfer of the case to the former
-is that the case was thus transferred in order that Coroner Hellenstein
might keep control of the proceedings pending against his friend. Though




42


the case was thus taken from Coroner Holtzhauser, the death certificate filed
on February 2d contained his certification that he had " taken charge of the
body of the deceased."
Coroner Hellenstein testified that before taking the case he inquired
of Deputy Assistant District Attorney Breckinridge of the Homicide Bureau
of the District Attorney's office whether there was any objection to his so
doing, in view of the fact that a friend of his was concerned therein, and
that Mr. Breckinridge replied in the negative. Mr. Breckinridge, however,
had no knowledge of the acceptance of the defective bail bond and of none
of the other significant circumstances to be later mentioned. Assuming,
therefore, that the Coroner's story as to his inquiry of Mr. Breckinridge is
true, it would seem to indicate nothing more than an attempt on the part of
the Coroner to cover himself against the conclusion which is inevitable
from his later handling of the case.
A PACKED JURY.
In the interval between the date upon which the bail bond was executed,
February 1st, and the date of the inquest, February 21st, the physician
defendant had several interviews with Coroner Hellenstein at the latter's
home. In the course of these interviews the jury which was to sit with the
Coroner upon the inquest was one of the subjects of discussion. The
Coroner told the defendant that there should be some doctors on the jury,
and asked him for the names of doctors whom he, the defendant, knew or
who were friends of the defendant, whereupon the physician gave to the
Coroner the name of Dr. Maurice A. Sturm, who had been acquainted with
the defendant for three years and who had met him through his sister, who
was the wife of one of the proprietors of the Ansonia Hotel, where Dr.
Sturm was then house physician. Dr. Sturm actually served as a member of
the jury. So did two other physicians, one of whom, the foreman of the
jury, was a long-standing friend of the Coroner's, who had also treated him
professionally and whom the Coroner, at a meeting of the medical association of which they were both members, had asked to serve on this jury,
telling him the name of the defendant, whom the physician also knew, and
the nature of the charge against the defendant. The third physician who
served on the jury was an acquaintance of Coroner Hellenstein's and was
closely affiliated professionally with the second of the physician-jurors. One
of the laymen who served on this jury was a member of the Hungarian
Republican Club with both the Coroner and his secretary.
Both the Coroner and his secretary testified before me falsely, as I must
find, that all the members of this jury were chosen at random and that the
names of the medical men who were members thereof were chance choices
from a medical directory. At a subsequent session, however, Coroner
Hellenstein testified as follows:




43


" A. After I put it down to take testimony and fixed the calendar.
During the days that the calendar was fixed and subpoenas have been
sent out this friend of mine visited my home.
" Q. That is, the defendant in the case?
" A. Yes, he visited my home and started in a conversation and
asked me how long and when we would get through and things like
that. I told him it is put down on the calendar and he actually
expressed himself, 'How does it look '?
"I said, 'I don't know how it looks for you. That is for the
jury. I have impaneled a good jury and amongst them have impaneled physicians who will do nothing else but justice. If you are
guilty they will find you guilty; and if you are innocent they will find
you innocent.
"And to tell the truth I must have said some names amongst
those physicians.
"Q. You must have done what to tell the truth?
"A. I must have said the names of some of the men. And it
happened I received from one doctor a message to my office who
begged to be excused as he has to go away. And I told him what
doctors had been there and I told him no more than three will be
served.
" Commissioner Wallstein-What is the rest of that answer?
"A. (Repeated as follows:) And I told him what doctors
had been there and I told him no more than three will be served.
"Q. You told that to him that day when he visited you?
"A. That no more than three, however, will serve on the jury.
"Q. Did you tell him who those three would be?
"A. I could not tell him all of them.
"Q. Did you tell him who they were?
"A. I knew the names at that time.
"Q. But I ask you, did you tell him the names?
"A. I could not tell if I told the names and things like that
but I must have dropped in my conversation some of the names.
"Q. You say you must have dropped in your conversation some
of the names?
"A. Yes."
(Record public hearings, pages 985, 986.)
CORONER RECOMMENDS DEFENDANT'S COUNSEL.
Another subject of discussion during the visits of the physician defendant at Coroner Hellenstein's house was the matter of counsel to be
retained by the defendant. The defendant suggested one attorney, but
abandoned his choice on the Coroner's statement that the attorney named
was not a criminal lawyer and that the defendant had better engage another




44


attorney, who was then named, and who actually appeared as the defendant's
counsel upon the inquest.
It is almost unnecessary to add that the finding upon the inquest was
that the deceased had died " following an abortion, the cause of which is
unknown to the jury "; whereupon Coroner Hellenstein subscribed the statement that " there being no sufficient evidence for me to believe the withinnamed * * * guilty of the offense within mentioned. I order him discharged."
In connection with this case it should be added that upon receipt of the
subpoena to appear before me, the physician defendant, that same evening,
had a personal conference with Coroner Hellenstein at his house in which
the physician was told that he probably would be questioned about the
doctors who sat on the Coroner's jury in his case. It is admitted, both by
the physician and by the Coroner, that this personal conference followed
immediately upon a telephone interview between the two. The Coroner
insists, however, that the sum and substance of the personal conference was
his statement to the physician that the latter when testifying before me
should tell the truth. The Coroner does not explain why that simple
message could not have been delivered to the physician in their telephone
conversation.
CRIMINAL ABORTION CONCEALED.
In the case of Margaret O'Neill, who died July 28, 1911, the house
physician at Flower Hospital recorded that the patient was suffering from
injuries due to " supposedly unnatural causes * * * supposedly due to
emptying of uterus * * * cervix widely dilated. Uterus enlarged and
emptied  * * * injuries said to have been received from emptying of
uterus * * * we curetted but uterus was empty." Under the head of
"remarks," the physician recorded: "She says instruments were used
while on the examining table." Dr. Lehane, the Coroner's physician, who
performed the autopsy, quite contrary to his course except in cases that he
regarded as involving criminality, made an attempt in his report to record
the facts disclosed by his autopsy. There is no record in the papers of any
notification to the police or of any report by them. The papers were not
filed with the District Attorney and his office had no knowledge of the case.
Such degree of publicity as is incident to having a jury sit with the Coroner
was absent, because there was no jury in this case despite the fact that,
there being obviously reasonable ground to suspect a crime, the calling of
a jury is mandatory. An affidavit by a sister of the deceased, in the handwriting of Mr. Schwartz, states her opinion that the deceased came to her
death by septicaemia and peritonitis following abortion "caused in a manner
and by persons unknown to deponent." Though criminal interference was
here conceded in an affidavit, which was unquestionably intended to serve
the purpose of excusing the Coroner's conduct of the case, no evidence of
investigation to ascertain the unknown persons can be found in the record.




45


The Coroner's finding was that the deceased came to her death " by septicaemia and peritonitis, abortion in a manner unknown." Coroner Hellenstein admits that he " might have used bad judgment in this particular case."
(Record public hearings, page 1071.)
In the case of Catherine Salvi, who died April 5, 1912, the cause of death
reported to the Coroner's office was " laceration of vagina." Dr. Weston,
upon autopsy, stated the cause of death to be "acute general peritonitis
following perforation through vaginal wall in attempted abortion." The
Lying-in Hospital, where the patient died, found upon admission that she
was suffering from "laceration of vagina and protrusion of intestine into
vagina." The affidavit of a woman acquaintance of the deceased named the
physician to whom she had taken the deceased, who was alone with the
deceased in his office for " a few minutes," and who thereafter, at the home
of the deceased, "worked on her " with another physician. The affidavit
of the husband in substance accused the woman just referred to of having
taken his wife to the physician named for the purpose of having an abortion
performed, and stated that at the hospital his wife before death had informed
him in effect that the physician had performed the abortion. With all of
this evidence to compel a finding of reasonable ground to believe that a crime
had been committed no jury was called. The papers in the record contain a
charge of attempted blackmail by the physician against the husband, but the
husband, who cannot make himself understood in English, produced before
me the woman who acted as interpreter for him at the time of the conversation in which the alleged blackmail occurred and who corroborates him in
his testimony showing that no such attempt was made. The husband also
produced before me two witnesses who were not called by the Coroner, and
who testified as to dying declarations made by the deceased accusing the
physician of having performed an abortion. The physician concerned in the
case testified before me that he had had an interview with the Coroner, of
which no record appears in the papers, and that at that interview his testimony or deposition was not taken. The papers in the case were not filed
with the District Attorney, but with thousands of other cases, were filed with
the Health Department when this investigation was begun.
The Coroner's finding was that the deceased had died from "acute
general peritonitis following perforation through vaginal wall in attempted
abortion in some unknown manner." As to this case, Coroner Hellenstein
admitted that there was no doubt that he should have had a jury, could not
explain why he failed to have one, and conceded that his conduct of the case
exhibited "a pretty bad way of doing things."  (Public hearing record,
pages 1139, 1147.)
In the case of Annie Benes, who died June 13, 1913, while the Metropolitan Hospital reported that "it is said that she suffered spontaneous
abortion," this was negatived by Dr. Lehane's finding on autopsy of a perforation of the uterus. This he described as follows: "On the posterior
border of the uterus midway was an oblique opening which measured about




46


the size of a pea which led into the cavity. This opening had a jagged
border and had three stitches closing it." Despite the strong indications of
crime admitted by the Coroner to be here present, no jury was called. There
is no record of notification to the police or of report by them, and no record
of the examination of any witnesses, though the name of a physician appears
in the hospital report. The papers were not filed with the District Attorney
and his office had never even heard of the case. The case was "closed
upon the papers " with a finding over Coroner Hellenstein's stamped signature that the deceased had died of "septicemia following abortion with
operation (sic) of uterus."
In the case of Annie Nike, who died February 17, 1913, Bellevue Hospital reported that " on January 4, 5 and 6, pills were taken to produce abortion. On January 9, 1913, she was curetted by an outside physician (name
not obtained)." The Coroner's physician (Dr. Lehane) found on autopsy
that death was caused by " sepsis following abortion, 4 weeks; said to be
spontaneous." There was no jury; the District Attorney neither received
the papers nor had ever heard of the case; there is no record of any effort,
through the police or otherwise, to ascertain the origin of the pills or the
identity of the "outside physician" who did the curettage; nor is there
record of any evidence to sanction the report of Dr. Lehane, adopted over
the stamped signature of Coroner Hellenstein, that the abortion was " said
to be spontaneous." A further odd circumstance is that the automatic time
stamp in the official report-of-death sheet shows that notification of the death
was received at the Coroner's office on February 18th, while the inquisition
papers are all dated February 17th, which, also, is the day before the hospital
report was made. Coroner Hellenstein admitted that the handling of this
case was characterized by laxity.
CORONER CALLS OFF POLICE.
In the case of Annie Kucera, who died October 22, 1913, the Coroners'
office was informed by Mt. Sinai Hospital that the deceased was " said to
have been operated on by some midwife, name and address not known."
The hospital report contained the further entry that the patient "ten days
before admission was to a midwife who used instruments within uterus
(nature of instruments, name of midwife could not be ascertained)."  Dr.
Lehane found that death was caused by " septic peritonitis, abortion criminal, perforation at fundus size of a goose-quill." At the foot of the reportof-death sheet are the names and addresses of a physician and a midwife in
pencil, and also the words "Detective Skelly." The District Attorney's
office did not receive the papers, and was not informed of the case. The
testimony or deposition of no witness is in the record. Detective Skelly reported to headquarters, under date of November 21, 1913, that the deceased's sister named the physician and the midwife who had treated the




47


deceased, the names being those before referred to. The detective's report
further reads:
" I immediately acquainted Coroner Hellenstein with the facts in
my possession. He ordered me not to make an arrest, as there was
not sufficient evidence, stating that he would subpoena both physician
and midwife to his office for investigation. Am still awaiting instructions from Coroner Hellenstein."
As before stated, no record of any examination of the physician or of
the midwife is to be found. The case was " closed upon the papers " with
Coroner Hellenstein's finding, over his stamped signature, that death was
caused by " septic peritonitis, criminal abortion, perforation at fundus size of
goose quill, induced by some unknown person."
A JURY MISLED.
In the case of Catherine Vogel, who died December 12, 1910, the
Coroner's physician recorded his finding by autopsy that death followed a
criminal abortion. On the inquest, when the physician's finding was read
to the jury, the word " criminal " was omitted, and the jury found that there
had been an abortion " induced in a manner unknown to the jury."
A SUSPICIOUS AFFIDAVIT.
In the case of Mary Fuchs, who died July 3, 1912, Mount Sinai Hospital
reported that the case was one of " abortion induced, 1 z months pregnant."
The affidavit of a woman friend of the deceased told of the latter's visit to
the office of a physician, naming him, of her calling him to her home when,
with another physician, he treated the patient again, and of this statement by
the deceased: " Call up Dr. Gladman and give me a knife. I will kill him
the way he killed me." The physician mentioned had been convicted in 1903
of performing a criminal abortion in Syracuse, and in 1911 of practicing
without a license. He also made an affidavit before the Coroner in which he
told of the deceased's visit to his office, of his subsequent call to the house
in which she was staying, and of a curettment performed in his presence by
the other physician whom he had called. The Coroner, Hellenstein, did not
direct the arrest of either physician, no jury was called at the inquest, no
papers were filed with the District Attorney, and the latter's office had no
knowledge of the case. Several of the witnesses who, my investigation
developed, had knowledge of the case had not been summoned, including one
physician, called by the girl's father, to whom she had made an ante-mortem
statement specifically accusing one of the physicians referred to. The case
was " closed upon the papers " with the Coroner's finding, this time attested
by his written signature, that the deceased died as the result of an abortion




48


" caused in a manner unknown." Among the papers in the record is an
alleged affidavit of a policeman in which he is made to say that he
"made diligent effort to obtain all the witnesses possible who may
know something about the girl's condition; that all the witnesses I
have been able to obtain have been subpoenaed to the Coroner's office
and examined by him; that the deceased died without giving any
information as to who was the cause of the pregnancy or to who
performed any operation, if any; that none of the witnesses knew
anything about same and deponent is unable to get any further
information; that he is of the opinion that the deceased came to her
death by an abortion brought about and performed by some person or
persons unknown and in a manner unknown by him, or whether it
was induced by the deceased herself."
The affidavit is in the handwriting of Mr. Schwartz and purports to
have been verified before the Coroner on July 7, 1912. The policeman's
signature appears four lines and a half below the last word of the affidavit
itself.
Coroner Hellenstein, when examined concerning this case, admitted
that this was a very unusual kind of affidavit, and that it looked as if somebody in the Coroner's office were interested in having it appear that the police
approved the investigation made-a circumstance which the Coroner stated
that he himself regarded as suspicious.
The Coroner's suspicions are confirmed by the testimony of the policeman before me, which I credit despite the denials of Mr. Schwartz, to the
effect that he had never been sworn and had never verified an affidavit in this
case, that he had not been before the Coroner on the date of the jurat, July
17, 1913, that some of the allegations contained in the affidavit were false
to his knowledge, that others were as to facts entirely beyond his knowledge,
and finally, that his signature to this paper must have been obtained on one
of the occasions when, at Mr. Schwartz's request, one of them being in a
hurry, Schwartz had suggested that he sign a paper in blank, leaving him,
Schwartz, to fill in the affidavit subsequently.
THE DEPTHS OF A CORONER'S IGNORANCE.
In the case of Antonia Fumerolla, who died May 20, 1914, a midwife
was arrested charged with having inserted a hairpin into the vagina of the
deceased with intent to perform a criminal abortion. Upon the inquest, at
which a jury sat with Coroner Hellenstein, there was evidence to the effect
that the midwife found the deceased suffering from a bleeding uterus in
the fourth month of pregnancy, took a hairpin from her head, straightened
it out and introduced it into the vagina of the deceased.
The law (Laws 1907, chapter 432) and the Rules of the Board of




49


Health are explicit in limiting the practice of midwives to assistance in cases
of normal childbirth, in prohibiting rigidly the use of any instrument at
childbirth, in enjoining scrupulous cleanliness upon midwives, in prohibiting
their attendance in cases where bleeding from the uterus develops and in
forbidding even the possession of any instruments other than those specially named, which list of permitted instruments does not include a speculum.
Yet the Coroner's charge to his jury, over the vigorous and repeated
objection of the District Attorney-thus demolishing the position occasionally advanced that the Coroner takes his law from that official-was
as follows:
"A few days later that bleeding went on, and a midwife was
called in.
" The question for you to decide is, was she a licensed midwife?
If she was, she had an absolute right to interfere with this woman.
If the woman was bleeding, and she was called in by the husband to
look after her health, she was justified in examining and treating her.
One of the witnesses states that there was a bulging of the bladder.
Therefore, to facilitate the delivery of this woman she could in a
proper case, if she sterilized it, use a hairpin or a toothpick or anything else. The question is, was she careful enough in using the
hairpin while puncturing the bag, or in using any other instrument
in removing the afterbirth?
" The question is, what did she use? She used, perhaps, a speculum. There is no testimony that she used any forceps."
*    *    *    *    *
" It is up to the midwife. If she is duly licensed she had a right
to use that hairpin. The only question to decide is, was she careful
enough. If she used a hairpin, or a toothpick, to puncture the bladder, she was justified as a licensed midwife."
"This midwife was called in by her husband. She was in later,
and she was bleeding; to hasten the delivery and relieve the woman
she was justified in doing what she did."
(Inquest Minutes, pp. 22, 24, 25.)
Aside from the other grossly erroneous features of the charge, there
had been up to this point no slightest evidence that the defendant was a licensed midwife. This is shown by the following extract from the minutes:
" A Juror-Was the midwife a licensed midwife?
" The Coroner-I haven't any proof of that, because she refused
to take the stand.
" Another Juror-Didn't you state she was a duly licensed midwife?
"The Coroner-Ask the defendant if she is duly licensed."
(Inquest Minutes, p. 25.)




50


After it was established that the midwife was licensed the Coroner
resumed:
" All you have to bear in mind is, the question was this woman
bleeding? Did she suffer from threatened abortion when the midwife was called in? Was she a duly licensed midwife; and if she was
she was absolutely correct and had a right to use her best judgment
to relieve this woman from her suffering."
(Inquest Minutes, pp. 35-6.)
Nor was there any evidence of any antiseptic precaution taken by the
midwife or of the fact that it was a speculum which had been used by herthough even its use was prohibited.
The jury could not have been much aided by this, which also is taken
from the minutes:
" Mr. Murphy-Your Honor, I ask you to charge the jury that
they must determine the facts as they find them adduced from the
evidence of the witnesses, and not by any summary of the Coroner.
" The Coroner-I charge you to take notice of the District Attorney's request, which I grant.
" Mr. Murphy-I ask your Honor to charge the jury not to consider the charge of the Coroner, particularly that portion of it in
which it is stated that when a midwife was called in instruments were
used by the midwife within her discretion, and that they are to pay
attention to the evidence adduced, and not to the charge of the
Coroner.
"The Coroner-I so charge, gentlemen. The request is granted."
(Inquest Minutes, p. 23.)
Of course the jury discharged the defendant.
With difficulty the Coroner was, when examined, brought to admit that
a hairpin was an " instrument " included in the statutory prohibition against
the use of instruments. Some of the law which the Coroner's charge outraged he also admitted he knew at the time. His only explanation of his
charge was that in his handling of the case he deliberately chose to be
governed by " common sense " rather than by the law.
For many years the District Attorneys in this city have found it unusually difficult to obtain convictions in cases of death following criminal
operation. Much of this difficulty, of course, is inherent in the nature of
the cases. Much, however, must also have been due to the Coroners'
handling of cases before they reached the District Attorney's office.
UNDERTAKERS' GRAFT.
One of the most revolting evils of the present Coroners' system may
be described as undertakers' graft. Before the body of the victim is cold




51


there often appears at the home of the bereaved family an undertaker who
seemingly has had wireless information of the death. The information
which leads the undertaker to the spot thus early does not in every case proceed from the Coroners' Office. Nevertheless the conclusion is unescapable
that in many cases it does proceed from the Coroners' Office. The further
conclusion is unescapable that at various times specific Coroners have had
agreements with specific undertakers in accordance with which the Coroner
does everything in his power to force the families of deceased persons to
engage the favored undertaker. The abuse has even gone so far that
a Coroner has not scrupled to arrive at the scene of death accompanied in
person by the undertaker. There is ample evidence to show that among
the methods used by the Coroner to force the family to take the favored
undertaker, is the threat to send the body to the Morgue or to perform an
autopsy when the cause of death is perfectly apparent; as for instance.
where a man has committed suicide by shooting himself through the head.
There is ample evidence to show that these threats have been withdrawn
when the favored undertaker was accepted by the family, thus proving conclusively that the threats were made not because the Coroner considered it
his public duty to send the body to the Morgue or to cause an autopsy to be
made, but simply and solely because he desired to oppress the family of the
deceased person. The testimony also clearly establishes that the Coroner
has stated that he can give a removal permit only to an undertaker whom
he knows. The ignorance of our Coroners is sufficiently great without
compelling us to believe that he did not know this to be untrue.
The operation of the favored undertaker system was clearly revealed
in the case of Siegfried Hayman, who committed suicide in the City Club
on August 11, 1911. This case came within the immediate knowledge of
Mr. Robert S. Binkerd, Secretary of the City Club, whose testimony was
corroborated on every essential point by Mr. Harry W. Newberger, formerly
Deputy Police Commissioner.
Coroner Holtzhauser arrived about half an hour after the Coroners'
Office had been notified. He was accompanied by an undertaker named
Leon T. Stowe. When the brother of the deceased expressed the wish to
engage the family undertaker, the Coroner threatened to send the body to
the Morgue and he also insisted that he could give a permit only to an
undertaker whom he knew. He introduced the undertaker whom he had
brought with him. He intimated clearly that all inconvenience could be
avoided by employing the said undertaker; that he was prepared to make
trouble for the family of the deceased if the said undertaker was not employed. The undertaker finally was employed. He simply removed the
body to his own establishment and embalmed it and it was then taken in
charge and buried by the family undertaker. For the work performed
Undertaker Stowe submitted a bill for $250. Payment was at first refused
on the ground that it was excessive, but the bill was finally paid as rendered.




52


CIVIL RIGHTS PREJUDICED.
As matter of law, the findings of the Coroner and his jury are not binding. A person held by the Coroner to be a suicide may later in court be
proved to have died a natural death, or vice versa. Nevertheless, as a
practical matter, an adverse finding by a Coroner's physician and a Coroner
may be very difficult to overcome, and, in any event, materially encourages
or discourages the enforcement of civil rights. It must be remembered
also that a considerable number of the ignorant come in contact with the
Coroner's Office and may have no knowledge whatever of the absence of
binding force in the Coroner's action. Therefore there is great opportunity
for unfairly affecting civil rights and liabilities by the Coroner's finding.
The two fields in which these evils have most clearly developed are in
the matter of life, accident and liability insurance; and, until recently, in
connection with questions of negligence in the employment of operatives
in factories and workshops.
A large number of life insurance policies are voidable during their
earlier stages if the insured dies by suicide. Life insurance companies are
therefore keenly concerned in the difference between a death by suicide and
a death due to a natural cause. Again, liability under accident insurance
will stand or fall with the determination as to whether or not the deceased
died as the result of an accident or by suicide or as the result of some
natural disease. Liability insurance companies are deeply interested in the
determination of the question of negligence in the operation of automobiles,
the owners or operators of which they have insured against liability.
Without further elaboration it is sufficiently clear that large sums of
money are often involved in the determination of the cause of death.
As an example of the manner in which the Coroner's action may unfairly affect matters in connection with insurance, the case of the Reverend
James Ross, of London, Ontario, Canada, may be cited. He died on November 18, 1913, as the result of being run down by an automobile, the
owner of which was one Leon T. Stowe, who held liability insurance under
a policy issued to him by the Aetna Life Insurance Company of Hartford.
The fact that no jury was called to sit with the Coroner upon the inquest,
despite the mandatory provision of the criminal code which the Coroner
knew to be applicable, has already been mentioned. In addition to that,
Coroner Hellenstein's conduct of this case was in other respects nothing
short of scandalous. Though Mr. Stowe was well known as an undertaker
of substance, who, indeed, had frequently in the course of his business been
in contact with the Coroners' Office in Manhattan, a subpoena requiring his
presence at the inquest was addressed to " Chauffeur Leon T. Stowe Chauffeur." The subpoena was in the handwriting of Mr. Wahl, and if the
testimony of Coroner Hellenstein is to be believed, he had not inspected
the subpoena prior to its issuance. Coroner Hellenstein knew at the time
of the case that Mr. Stowe was an undertaker, had at that date known it
for some time, had met him personally, and knew that Mr. Stowe was a




53


friend of Coroner Holtzhauser, who was then also in office. Yet upon
the inquest counsel entered his appearance as attorney for "Defendant
Chauffeur," and Mr. Stowe testified, without objection or correction by the
Coroner, in response to a question asking his occupation, that he was a
chauffeur. The Coroner's connivance at the device of posing as a chauffeur
was well calculated to discourage civil proceedings to collect damages for
the death of Mr. Ross, particularly in view of the fact that his home and
his family were in a distant city whence the ascertainment of the true facts
was less easy than usual.
The failure to call the required jury would seem, therefore, to have
been not merely an instance of the usual laxity in that regard; rather it
would seem to have been intentional, for the purpose of facilitating the
result which was reached in this case.
Two days before the inquest was actually held, a representative of the
New York office of the insurance company, then at London, was in position to write to his superiors in New York that the company's London attorneys knew what the Coroner's verdict would be. This advance knowledge is not surprising in view of the fact that, when the inquest was held,
several witnesses, whose names appeared as such upon the police blotter,
were not called to testify, including particularly among those not called one
as to whom Mr. Stowe had written to the insurance company that she was
not friendly and that she had better be interviewed at once. It was significant that Coroner Hellenstein remembered this case, but conceded his
complete inability to offer any explanation of his conduct of it, though he
admitted that it was filled with " odd circumstances." The finding of the
Coroner was that the deceased had been "accidentally struck by an automobile owned and operated by Leon T. Stowe."
Before the passage of the Workmen's Compensation Act the Coroner
had another fruitful field of abuse in cases which involved death by accident in factories, machine shops, etc. A flagrant case arising in the Borough of the Bronx under the administration of the late Coroner Schwannecke is disclosed by the testimony of Edward A. Moree, who served upon
the Coroner's jury, in the inquest on the death of Charles Lang, May 3,
1911. Lang was an oiler and belt fixer in the Johnson Iron Works, who
died as the result of injuries received in the course of his employment.
Moree testified:
"A good many witnesses were sworn that seemed to me not to
throw any great amount of light on the situation, and finally the
superintendent or master mechanic came on the stand, and it seemed
to me that the cross-questioning by the Coroner did not bring out the
facts in the case which some of the chance remarks of the witnesses
previously had led me to believe were of a damaging nature to the
Iron Works, and I asked a witness some questions and brought out
some of the facts. Finally the Coroner objected to my asking any




54


more questions and excused the witness, and I protested mildly as I
remember it.
" When we got into the room to consider the case I found that
other members of the jury had had the same doubts as to the
validity or some doubt as to the desire of the Coroner to bring out
the facts, and we went back in and asked that the witness be recalled."
Mr. Moree, who was the fourth juror in this case, then proceeded to
question the witness who had been recalled. He was soon interrupted by
the Coroner, as follows:
" One moment, Mr. Juryman. The evidence is in that this man
was absolutely competent, from his personal experience, in performing this work. The evidence is in that if he had asked the power to
be shut off while he was making the repairs, it would have been
shut off. He was the sole judge as to whether that power should be
shut off or not, and he didn't do it, and I direct the jury to bring in a
verdict of culpable carelessness on his own part for the injuries from
which he died."
The record then proceeds:
" Fourth Juror-I would like to see the law, Mr. Coroner, on
that point.
" The Coroner-You have heard my decision. Juror No. 4 is
excused.
" Fourth Juror-I protest against
" Third Juror-I wish to stand with Juror No. 4. I am with
Juror No. 4.
" The Coroner-Why, you are taking up a lot of time for nothing at all. He wants to read the law when I am making a charge.
It is contempt of court. I am quoting the law to you."
Without quoting more from the record, which is spread fully upon the
minutes of the Public Hearings, pages 825-836, the conduct of this case by
the Coroner was scandalously injurious to the rights of the family of the deceased workman, and obviously biased toward helping to make for the employing corporation a case which would relieve them of any liability for
their workman's death.
WASTEFUL ORGANIZATION.
The incompetence and waste of the elective Coroners' system is well
exemplified in the organization and conduct of the clerical staff attached to
the office. Upon this general situation Coroner Feinberg testified as follows:
" It is a fact that the salary paid to the lay Coroner and to unnecessary subordinates, makes it impossible to pay adequate salaries




55


to properly qualified men charged with the medical side of the work
and militates against the employment of such men under the present
system.
" It is a fact that the lack of any central control over the work
of the Coroner's Office produces waste and confusion and inefficiency." (Record of Public Hearings, p. 380.)
While satisfied that this condition exists throughout the city, special
study has been made of the situation in the Borough of Manhattan. Besides
the four Coroners and their four physicians, the organization of the Coroners' Office in Manhattan is as follows:
1 Chief Clerk at $3,000 per year.
1 Property Clerk at $2,200 per year.
2 Assistant Clerks at $1,800 per year.
1 Assistant Clerk at $1,500 per year.
2 Night Clerks at $1,500 per year.
1 Official Stenographer at $2,500 and fees.
1 Unofficial Stenographer at $1,000 per year.
4 Private Clerks at $2,000 per year.
The clerical payroll of the office is $24,800 a year.
AN ABSENTEE CHIEF CLERK.
The Chief Clerk, Antonio Dalessandro, is a Republican organization
leader in the Borough of Manhattan. Mr. Dalessandro says that his function is the general supervision of the work of the office. The testimony is
as follows:
From a former employee of the Coroners' Office:
Dalessandro would probably come in in the morning and we
would not see him again until toward evening and sometimes we
would not see him all day. I couldn't say that he was there even part
of every day. I think there were occasions when he was away whole
days at a time. (Record of Private Hearings, p. 648.)
From a newspaper reporter who was assigned to duty at the Coroners'
Office:
I didn't know Mr. Dalessandro until some time after I had
been assigned to the Coroners' Office, because I had not seen him in
the office at all. It was not until three or four weeks after I had been
assigned there that I saw Dalessandro.
During the first four or five months that I was at the Coroners'
Office Dalessandro appeared only occasionally. He was hardly ever
there and then only for a short time. He was away more than he




56


was present. He was away for whole days at a time and on days
when he did appear it was usually for a maximum period of one or
two hours.
He would usually come about 11 o'clock and leave about 1
o'clock.
On such days I have never seen him return. There were frequent periods of two or three days at least when he didn't appear at
the Coroners' Office at all.
When he was at the office I saw him with his hands in his
pockets usually talking and laughing with people. I never saw him
engaged in receiving notifications of death nor in making entries in
any books nor did I ever see him give instructions to anybody.
(Record of Private Hearings, p. 275.)
Together with Mr. LeBrun, an assistant clerk, Mr. Dalessandro ran a
boarding house in Far Rockaway during the summer of 1912. The records
show that 238 telephone calls went over the city wire to that hotel during
that summer.
Coroner Riordan testified that Chief Clerk Dalessandro was the " power
behind the throne " in the Coroners' Office in the Borough of Manhattan;
that he refused to perform services except for those whom he considered
to be the majority of the Board of Coroners.
OTHER CLERKS.
The duties of the property clerk are to take care of and return to the
proper persons property found on the bodies which come within the Coroners' jurisdiction and to act for the Coroners in replevin actions against the
Sheriff when such are necessary. For these services he receives, as above
noted, $2,200 a year. The records in the office show that since January 1,
1910, there have been an average of 962 cases per year in connection with
which property has been filed with the property clerk. This is an average of
about three cases a day. The records of the office further show that since
January 1, 1910, there have been exactly eight replevin actions in which the
property clerk has represented the Coroners, or less than two cases a year.
The specific duties of the property clerk are not calculated to consume even a
fair portion of an average working day.
Assistant Clerk George Wahl, according to the testimony, is probably
more assiduous in his daily attendance upon his duty than most of the other
employees. He has been in the office for many years and there is apparently
no function to which he cannot and will not turn his hand. One witness
testified as follows:
I saw Mr. Wahl write up the papers for the Coroner he was
assigned to. He used to also write up the papers for other Coroners
whose clerks would be absent or doing some other work. He would




57


also take charge of the office, relieve the property clerk and attend
inquests.
When he attended inquests he would call out the names of the
witnesses, swear the witnesses, would hand the papers to the Coroner,
would unfold them and open them, and would swear the jury and
take charge of the proceedings. (Record of Private Hearings, p. 285.)
Assistant Clerk George LeBrun is the bookkeeper and auditor of the
Coroners' Office. The records from January 1st to November 15, 1914,
show that this work consisted of the following:
42 orders issued
81 invoices received and audited
65 vouchers prepared and entered
31 payroll vouchers prepared, each payroll consisting of 21 names
The keeping of two books:
1. A fund ledger which contains six live numbers.
2. A general ledger.
A witness who has had long experience with the Coroner's Office testified:
LeBrun was usually present in the Coroners' Office each working day. He missed whole days at times but generally not more than
one day at a time. When he was present he didn't always attend
during the whole day. I have seen him come in and go out again in
about an hour. This was not during his vacation. (Record of Private
Hearings, p. 284.)
Mr. LeBrun's ability, in connection with Chief Clerk Dalessandro to
run a summer hotel, has already been noted.
CORONERS' PRIVATE CLERKS.
In addition to the clerical staff of the office, each Coroner is by law entitled to a private clerk, of whom therefore in the Borough of Manhattan
there are four, each drawing a salary of $2,000 a year.
Their functions they describe as taking antemortem statements; assisting in the Coroners' Court; making up the calendars for the said court;
serving of juries; and the preparation of papers for the particular Coroner
to whom the clerk is attached.
The records show that only about 40 antemortem statements are taken
in the course of an entire year and that they are often taken by the Coroner
and not by the Coroner's clerk. The Coroners' Court is held but three times
a week. Juries are summoned but three times a week and there are only
three court calendars to be prepared in the course of a week. These figures
are the average figures for a number of years.




58


It is obvious therefore that the Coroner's private clerk has but little
real work to do. Even the service of juries is oftentimes not done by the
clerk; it is done by someone hired by the clerk for that purpose.
While this investigation was under way Coroner Hellenstein requested
Mr. Louis J. Schwartz, his private clerk, to give eight hours per day to the
work of the Coroner's office. In response to this request Mr. Schwartz
said that he could not afford to do so, and tendered his resignation, which
was accepted. In my judgment there are other reasons which would have
justified the termination of Mr. Schwartz's services.
The testimony as to how much time Mr. Schwartz gave to his work as
a Coroner's clerk is as follows:
Schwartz would spend sometimes one or two hours a day at the
Coroner's office and sometimes he would not show up there all day
long. Each Coroner has a week off each month, but there is sometimes work for the Coroner's clerk even then, closing up casessimple cases-stating the cause of death to be so and so, filling the
forms and filing them away; getting the jury ready, making up subpoenas, etc. Schwartz did not do that work. George Wahl did it
for him. (Record of Private Hearings, p. 654.)
Another witness testified:
When I was at the Coroners' Office, talking with the Coroner's
secretary, Mr. Schwartz, the latter was on the telephone talking his
own legal business. (Record of Private Hearings, p. 783.)
Mr. Schwartz's own testimony was as follows:
" Q. How do you divide the day between your law office and the
Coroners' office?
"A. I am at the Coroners' office whenever the work requires
me to be there; and I am at my private office whenever I don't
have to be at the Coroners' office.
" Q. Who determines when the work requires you to be at the
Coroners' office?
"A. The necessities of the office.
" Q. And it is your judgment that determines whether the
work there requires your presence there or not?
"A. As a general rule, yes." (Record of Public Hearings, p.
1280.)
The Coroner's private clerk sometimes accompanies the Coroner when
the latter is called to view cases. He never, so far as can be found, makes
notes, draws diagrams, takes photographs or does anything else materially
to assist in the preparation of adequate data upon such cases. So far as the




59


accompanying of the Coroner is one of his functions, he may properly be
described as a municipally paid companion and chaperon.
In spite of the fact that there are an official stenographer and all the
other clerical assistants noted, the Coroners of the Borough of Manhattan
have found it necessary to employ an unofficial stenographer to whose salary
the Coroners and the Coroners' Clerks contribute. Although she frequently
does official work, she has no official standing; and her employment outside
of and beyond the extensive clerical staff of the office is an added proof of
the waste, confusion and inefficiency which characterizes the work.
INCIDENTAL ABUSES.
Mr. Leonhard F. Fuld, an Examiner of the Municipal Civil Service
Commission, testified as follows:
"I asked the Chief Clerk whether he had any time records in
the office, both with reference to the office employees and to the employees in the field, and I was informed by him that there were no
time sheets, or books or time clock records in the office, and that the
office had no record of the time of service or the amount of work
performed by the various employees of the office."  (Record of
Private Hearings, p. 310.)
I recommended to the Civil Service Commission that the fact
that the Coroners' office had not installed the new system of time
records be brought to the attention of the Comptroller. (Record of
Private Hearings, p. 322.)
A number of incidental evils in connection with the clerical employees of
the Coroners' system have been noted. Thus the practice of recommending
to public service corporations the employment of friends has been indulged
in not only by the Coroners themselves, but by employees of the Coroners'
office.
Again, as has been seen, Coroners' Clerks and others have arrogated
to themselves the power to excuse from service persons summoned for jury
duty.
But there is a still more serious evil: Most of the Coroners generally
and all of the Coroners in the Borough of Manhattan have adopted the
practice of using a rubber-stamp signature, which is affixed indifferently to
affidavits, to inquisition papers and to other documents of a formal character. In questioning various Coroners concerning suspicious cases, the conclusion has not infrequently been compelled that the Coroner has seen the
papers presented to him on the witness stand for the first time in his life.
Reference has already been made to the case of Charles Lips, who died on
September 25, 1910; to the fact that the inquisition paper was cleared out
on the afternoon of the day on which the death occurred, which was a Sunday; that the inquisition paper was filed with the Health Department, al



60


though the death was of a suspicious nature, warranting a full investigation.
When confronted with this inquisition paper bearing his stamped signature, Coroner Hellenstein declared that he had never seen it before, and
this I believe to be true. It therefore becomes apparent that some employee
of the Coroners' office, entirely without legal authority, stamped the Coroner's signature.
It is also impossible to explain the widespread system of favored undertakers without admitting co-operation or connivance by some of the
employees of the Coroners' office.
CONDITIONS IN THE BROOKLYN OFFICE.
While an intensive study has been made only of the clerical force of
the Board of Coroners in the Borough of Manhattan, there is every reason
to believe that many of its faults have been reproduced in the other boroughs
of the city. Mr. Fuld, the Examiner of the Municipal Civil Service Commission, testified as follows with regard to the office conditions in the Borough of Brooklyn:
"On September 9, 1910, I called at the Coroner's Office in
Brooklyn for the purpose of inspecting efficiency records of that
office. The Chief Clerk was not in. After waiting for an hour I
left the office, stating that I would make an appointment for some
other date." (Record of Private Hearings, p. 421.)
On January 11, 1912, I called at the Coroner's office in Brooklyn with reference to the annual report of that department. I had
previously made an appointment to meet Chief Clerk Cuneen at three
o'clock. Mr. Cuneen was not in the office at the time of my call. I
was informed that he had been called over to the office of the City
Record on a matter of importance. I called up Miss McKennie,
Chief Clerk in the office of the City Record, who made inquiries at
that office, but was unable to find that anybody in her department
had asked the chief clerk to call. (Record of Private Hearings, p.
429.)
I have called at the Coroner's office in Brooklyn about twentyfive times, as shown by records in the office of the Municipal Civil
Service Commission and have been unable to see Mr. Cuneen or the
efficiency record book at any time.
I found no minutes and no reports on file in the Coroner's
Office in Brooklyn, and in accordance with instructions from the
Civil Service Commission I have not insisted upon the keeping of
records or minutes in the Coroner's Office in Brooklyn. I don't recall
that we waived the requirement of written reports in any case other
than that of the Coroner in Brooklyn.
I believe that the First Assistant Chief Examiner felt that more
time was being wasted in endeavoring to have the efficiency records




61


kept in the Coroner's Office in Brooklyn than they were worth.
(Record of Private Hearings, pp. 433 to 435.)
Coroner Wagner, of Brooklyn, testified that when he took office he
found that relatives of deceased persons were being charged $5 or $10
"according to how they were fixed financially" for copies of Coroners'
papers in connection with the death of the deceased in question.
He further testified:
" I understood that some of the clerks in the office were exacting
a fee and I stopped that when I placed that ( a rubber stamp to the
effect that no charge should be made) on the paper as soon as I
assumed office."
PRESENT EMPLOYEES AND A NEW SYSTEM.
In any legislation aimed at the elimination of present abuses it will be
of the highest importance not to give to the present employees of the Coroners' Office any statutory right of re-employment in connection with any new
organization of government which may supplant the Coroners. In saying
this I do not mean to imply that there are no competent and faithful men
among these employees who could not properly find a place in the new system; but such re-employment should take place only after a thorough investigation of the present employees and after a thorough weeding out of
those who are unfit.
SHEER WASTE OF PUBLIC MONEY.
The present Coroners' system costs approximately $175,000 per annum.
Its maintenance is a sheer waste of public money. The City gets no competent or adequate service from the lay Coroner in return for the $6,000 salary
which it pays him. The character of the medical work which the City receives from the $3,000 Coroner's physician has already been adequately
demonstrated. The previous finding has shown the waste in the office organization of the Coroners' system and an entire lack of justification for the employment of private clerks at $2,000 a year. A unit of the present Coroners'
system may be said to consist of a Coroner, a Coroner's physician and a
Coroner's clerk. For such unit the city pays the exorbitant sum of $11,000
a year. In return for this expenditure it receives the services of an unqualified Coroner, of a mediocre physician and of a clerk who spends most
of his time on his own private affairs.
In the legislation which will shortly be submitted, it is proposed to leave
to the Board of Estimate and Apportionment the determination of salaries,
number of employees and all other financial details in the organization of a
new agency to take over the Coroners' work. Nevertheless, the organization
which will become necessary has been sketched and shows that such a new




62


department can be operated for not less than $100,000 a year and not exceeding at a maximum $125,000 a year. These estimated figures include a competent staff of stenographers, including a stenographer to attend and take
detailed notes of the findings of every autopsy. They would include the use
of automobiles as a rapid means of communication, and the cost of keeping
the fullest and most adequate records. They include the cost of a sufficient
number of photographers to furnish the valuable evidence of a series of contemporaneous pictures in every homicide case. They include an adequate
force for chemical examination to detect poisons, etc., while at the same time
they contemplate salaries which would attract trained and skilled pathologists
instead of the present mediocre medical talent found in the average Coroner's
physician. In short, the system can be revolutionized as to efficiency,
while at the same time making a substantial saving which would certainly
amount to $50,000 a year or more.
In the appendix will be found a statement of the cost of the present
Coroners' system in this City.
THE ELECTIVE CORONERS' SYSTEM ELSEWHERE.
That the elective Coroner system is inevitably productive of great
abuse is likewise demonstrated by the experience of other communities which
have abolished or attempted to abolish similar systems.
(a) In England itself, where the system originated, the Coroners were
made appointive in the year 1888, their jurisdiction and combination of
functions remaining unimpaired. Nevertheless, the situation continued to
be far from satisfactory and was the subject of a Parliamentary investigation in 1908 (Encyclopaedia Britannica, v. 7, pages 187-188).
(b) In passing upon a case concerning Coroners' fees, the Hon. Harmon Yerkes of Bucks County, Pennsylvania, said:
" The office has been abused until its purpose has been perverted
to a money-making machine.
" The true remedy for abuse of the Coroner's office is its absolute abolition. We have had instances in this County where the
Coroner's blustering interference and bombast obstructed the investigation of serious murders " (February 26, 1900).
(c) A report by the Chicago Bureau of Public Efficiency, dated December, 1911, reaches the following conclusions with regard to the reorganized elective Coroners' system of the City of Chicago:
(i) That the professional jury system is a scandal.
(ii) That the deputy coroners require professional jurors to
split their fees with them, it being estimated that this graft in the
year 1910 amounted to between fifteen and twenty thousand dollars.
(iii) That in cases involving criminal negligence the coroner uses




63


stenographic copies of the testimony furnished by public service corporations, who are parties in interest.
(iv) That the coroner ought not to be an elective official.
(d) A report of the Municipal Association of Cleveland, Ohio, dated
December, 1912, finds:
(i) The office of coroner has long been a subject of comment
and unfavorable criticism in this county.
(ii) That the coroner does not co-operate with the authorities
for criminal prosecution, with obviously bad results.
(iii) That the autopsies performed by the coroner are valueless, both for vital statistical purposes and for criminal prosecution.
(iv) That the medical duties should be completely separated
from the legal duties of the office.
(v) That the office of elective coroner should be abolished.
(e) In a monograph published in 1910 by Dr. R. B. H. Gradwohl, a
former Coroner's physician for the City of St. Louis, Mo., he says:
" Many of us have seen or have heard of failure of the State to
prove the guilt of accused persons who seem to be practically convicted until examination and cross-examination of the State's most important witnesses, the Coroner's autopsy physicians, showed that their
work was inefficient and inconclusive, resulting in the acquittal of
possibly guilty people for want of convincing proof. (Page 22.)
"It is unnecessary for me to describe the laughable travesty on
justice which is continually going on in Coroners' courts because of
the failure on the part of the presiding officer either to understand or
to utilize the ordinary methods of court procedure." (Page 14.)
(f) Because of flagrant abuses in the elective Coroners' system it was
abolished in the State of Massachusetts in the year 1877, due largely to the
efforts of Mr. Justice Tyndale. The present medical examiner system was
substituted.
(g) Due to the abuses of the elective Coroners' system, the States of
Michigan, Connecticut and Rhode Island have adopted the Massachusetts
system.
(h) Owing to abuses developed the elective Coroner system was abolished and a medical examiner substituted in Erie County, N. Y., by chapter
577 of the Laws of 1902.
(i) The elective Coroner system has been abolished in the State of New
Mexico and the Coroner's functions devolved upon justices of the peace.
(Letter from Secretary of State, dated August 12, 1914.)
(j) On the second Monday in January, 1915, the duties of all coroners,
except in counties of the first class, will fall to the prosecuting attorneys in




64


the State of Washington. This change was brought about by chapter 55 of
the Laws of 1913.
(k) In the State of New Hampshire, by chapter 134 of the Laws of
1913, the elective Coroner system was abolished and the Coroner's medical
work transferred to a new officer, known as a medical referee.
THIS CITY'S EXPERIENCE.
The abuses which this investigation has disclosed have been found time
and time again in the history of the elective Coroners' system in this city.
In 1893 a New York County grand jury filed the following presentment:
" We believe that the long standing maladministration of the
Coroner's office in this County is a cause of embarrassment to the
interests of public justice, and that a more satisfactory means of discharging important functions now devolved upon the Coroner's office, namely:
" 1. Investigation of sudden and suspicious death, and
"2. The examination and commitment of persons charged with
causing such deaths,
-ought to be provided by law."
The grand jury further recommended that the subject be brought to
the attention of the then approaching Constitutional Convention with a view
to the abolishment of the office of Coroner.
The Constitutional Convention of 1894 discussed this question, and
amended the Constitution so that the Coroner ceased to be a constitutional
officer, in order that there should thereafter be no constitutional difficulty
in the way of abolition of the system by the Legislature.
In 1897 the elective Coroners of the old City of Brooklyn, Coombs and
Nason, were indicted for grand larceny, for presenting fraudulent bills for
audit and for filing false certificates of death. On one of these counts Coroner Coombs was convicted and sentenced to a fine of $500 and one year
and seven months in the penitentiary.
In the Borough of Manhattan the situation did not improve, and scandal and abuse continued to be characteristic of the system. In particular,
the conduct of the Coroner's office in the investigation of the Park Avenue
explosion, early in 1902, concentrated public attention on this question once
more.
Editorials of condemnation of the present system and a demand for its
abolition was voiced editorially by practically every newspaper in the city
during the month of February, 1902.
The Medical Critic, in its issue of June, 1902, said:
" Within the past few days a new and somewhat startling reason
for the abolition of the coroner has been published in the public newspapers under the heading' hanged herself in an hotel.'




65


"The coroner kept from the police and Board of Coroners the
fact that a violent death had taken place and showed an extraordinary
concern in surrounding the case with secrecy.
" When the coroner was questioned why he had not reported the
suicide he gave the following reasons:
"'I forgot. (My eyes trouble me a great deal.)  (I have too
many confinement cases.) (Anyway, it isn't anybody's business, as
no one killed her but herself!)'
" It seems almost impossible to believe that such imbecile and
ridiculous reasons were given for a plain violation of duty by an
official. While the coroner was behind the 'I forgot' excuse, a reporter asked him if it was not remarkable that he should forget to
report such a case, and the reply was ' Oh, no, I do it frequently.' "
In 1903 Dr. I. R. Purdy, a reputable member of the medical profession
in this city, published a report on " Why the Office of Coroner should be
Abolished." The result of the agitation which he started was the passage
by the Legislature of a bill abolishing the elective coroners' system, which
was vetoed by Mayor McClellan (May 3, 1904).
In 1905 Moses J. Jackson, an elected Coroner of the Borough of Manhattan, was indicted and convicted of having agreed to receive a bribe of
$500 as a result of which he undertook to clear a defendant of the crime of
criminal abortion.
Every proposed revision of the city charter, with the exception of the
so-called Gaynor charter, has proposed their abolition. Both the Ivins Commission and the joint committee of the Legislature which proposed the socalled Hammond charter, investigated the subject and concurred in the
recommendation for abolition.
In 1914 the Bar Association of the City of New York reported:
"The office of the coroner was a constitutional office until the
amendment of the constitution in 1894. The purpose of the amendment was to facilitate the abolition of the office and to enable the
legislature to transfer its functions and powers to other public officials.
In recent years coroners' inquests held in the City of New York have
been preposterous, and there has frequently arisen an unseemly conflict of jurisdiction between the coroners and the district attorney.
The men selected to the office of coroner have not ordinarily been of
such a type as to inspire confidence. Nor have they ordinarily been
possessed of either the scientific training or the judicial discretion
which is called for. * * * "
In the 1914 session of the Legislature a bill for the abolition of the
elective coroners' system was proposed by a committee representing the New
York Short Ballot Organization, the Academy of Medicine, the Young
Republican Club, the Citizens Union and the City Club of New York. This
bill was defeated, the coroners having created an organization known as the




66


Greater New York Coroners' Association, for the purpose of opposing the
legislation.
IMMEDIATE ABOLITION IMPERATIVE.
The constant recurrence of evils and abuses has demonstrated beyond
doubt that the present Coroners' system cannot be continued in the City of
New York except as a public scandal and disgrace. Abolition is the only
remedy. Such abolition is simple of accomplishment, because it requires
only giving back to the criminal authorities responsibility for criminal investigation; giving back to the judiciary the exercise of the magisterial functions of the Coroner; and the constitution of an efficient new agency for
medical examination.
The abolition should be immediate. There is no legal or moral contract to maintain the present Coroners in their positions and salaries. Every
day that they continue means waste of public funds, inefficiency, and continued opportunity for, and recurrence of, all the abuses which this investigation has found. So far as any moral rights are involved in the question,
the interests of the people of the City of New York have been flouted for a
generation, and they have a right to demand that this long-deferred reform
shall be now accomplished.
In Nichols vs. MacLean, 101 N. Y., 526, the court held:
" The right to hold an office and to receive the emoluments belonging to it does not grow out of any contract with the State, nor
is an office property in the same sense that cattle or land are the
property of the owner. It is therefore the settled doctrine that an
officer acquires no vested right to have an ofice continued during the
time for which he was elected or appointed nor to have the compensation remain unchanged. The legislature may abolish an office during the term of an incumbent or diminish the salary or change the
mode of compensation, subject only to constitutional restrictions."
The exercise of the undoubted power of immediate abolition is not
without ample precedent. The Coroners of the Boroughs of Queens and
Richmond who took office on January 1, 1898, themselves supplanted prior
Coroners, who were legislated out of office by the Greater New York Charter. (See Clapp vs. Guy, 31 Appellate Division, 535.)
The immediate abolition of the elective Coroner in New York City
would be entirely analogous to the abolition of the old elective office of
Police Justice in the City of New York, accomplished by Chapter 538 of
the Laws of 1873. (See Wuenzler vs. People, 58 N. Y., 516.)
MEDICAL EXAMINER SYSTEM IN MASSACHUSETTS.
In devising a new agency to take over and to perform competently the
medical functions of the present Coroners system, no experiment is neces



67


sary. The system of medical examiners has been in operation in Suffolk
County, Massachusetts, an urban unit of a million inhabitants, for nearly
forty years. Its success is beyond doubt. The character of its work and
of its records is so high as to make any comparison with our Coroners
hardly possible. Its medical conclusions are not a joke and its proceedings
are not a travesty or a disgrace; it has not conspired to set defendants free;
it has not concealed information from the criminal authorities; it has not
made disgusting alliances with undertakers; it has not used its powers for
extortion. It is seldom indeed that the choice between two methods of fulfilling a public function is as clear as the distinction between day and night.
The medical examiner system was substituted for elective Coroners
in Massachusetts in 1877. The examiner is appointed by the Governor for
a term of seven years. Both of the Suffolk County examiners, Drs. Leary
and Magrath, are trained pathologists of high standing. They investigate
yearly between 2,000 and 2,500 deaths covering substantially the same classes
as fall within the jurisdiction of New York City Coroners. A report of the
findings in each case is filed with the District Attorney. Wherever the
death is criminal, the finding is also filed with the police court. Any judicial
inquiry into a death is held before a police court or municipal judge, without
a jury. The medical examiner gives the medical testimony and the police
and the District Attorney co-operate in the criminal investigation.
The reports of medical findings and of autopsies are full and complete. Photographs and diagrams are constantly used. There is continuous and effective co-operation between medical examiner, district attorney
and police. It frequently happens that the first hint of crime comes from the
competent medical work of the examiner. A recent case in point was the
murder of Avis Linnell by the clergyman, Richeson. The death was merely
a sudden one, without adequate medical attendance and with no satisfactory
known cause of death. Autopsy showed potassium cyanide poisoning.
The total cost of the system in Suffolk County is about $32,500 per annum. The average cost per case for 1912 was $15.45. Inquests or judicial
inquiry were necessary in but 12.3 per cent.; autopsies in but 25.3 per cent. of
all cases.
No equally satisfactory system has been yet evolved in the United States.
The medical examiner system of Suffolk County is to-day the best known
method of applying the science of legal medicine to the safeguarding of the
community.
MEDICAL EXAMINER SYSTEM FOR THIS CITY.
The application of its principles to the situation in New York City will
require:
(a) That the function of the new department of medical examination shall begin and end with the adequate and accurate determination of the physical cause of death.




68


(b) That the head of this department shall be appointed by the
Mayor from a list of competent, trained physicians and pathologists.
(c) That this new department shall be subject to continuous
central control, so that any misfeasance or nonfeasance on the part of
any of its employees may be visited with trial and dismissal.
(d) That all work of criminal investigation shall be handled by
the police and the various district attorneys.
(e) That preliminary hearings in homicide cases shall be held
before a city magistrate.
(f) That the Coroner's Court and the Coroner's jury shall be
abolished, and that no inquest shall be held except as preliminary
hearings in homicide cases, as above.
(g) That full and adequate records of the medical findings of
this new department shall be kept in each and every case, made public
records, and put at the disposal of the criminal and health authorities
of the City and also be made available to all parties in interest in any
litigation arising from the death of the deceased.
SELECTION OF COMPETENT HEAD.
The necessary legislation to abolish the present Coroners' system and
to establish a department of medical examination is in process of preparation and will be submitted at an early date. Attention is directed to the
method of determining the qualification which the officers of this new department must possess. In connection with this investigation the method of
"non-assembled examinations" used by the United States Civil Service
Commission in the selection of men of high technical knowledge and training, has been examined. In my judgment, the head of the proposed department of medical examination and his assistants should be chosen by this
method. The legislation in process of drafting will not, of course, specifically require this, since it is entirely possible that in years to come a still
better method may be found.
The President of the United States Civil Service Commission thus defines such examination:
" The term 'nonassembled' is applied to these examinations to
distinguish them from the examinations which require that candidates appear at a designated place for the purpose of undergoing a
scholastic or other written test composed of questions on subjects
with which a properly qualified person should be familiar. The
nonassembled examinations are, however, in the highest sense competitive. The Commission undertakes by means of them to determine the relative order in which the candidates are entitled to consideration for appointment to the position to be filled.
" This type of examination is applied to positions of a high grade




69


where men of attainments are needed-positions for which it would
be difficult or impossible to devise a scholastic or categorical question-and-answer assembled examination adequately testing qualifications needed. Positions of the kind described required either men
who have specialized along some special scientific or technical line,
who have had successful experience in the practice of a profession,
or who have demonstrated by actual experience ability to manage and
conduct responsible work of a professional, scientific or technical
character.
*           *           *           *           *           *
"The examination is usually divided into two or more subjects,
or elements, with relative weights in accordance with what the Commission, after free consultation with the appointing officer, considers
their relative importance to be. For example, in the examination for
chief bacteriologist, before referred to, a weight of 40 in 100 was
given to general education and scientific training, a weight of 30 to
practical experience and fitness, and a weight of 30 to publications
along bacteriological or pathological lines. Sometimes a thesis on
some phase of the work is required, either in addition to or in lieu
of exhibits of published works. The subject of the thesis may be
prescribed by the Commission, or the applicant may be permitted to
select his own subject, depending upon the nature of the position to
be filled. In any case the applicant is permitted to prepare his thesis
at home, but is required to make oath to the fact that the preparation
of the material and the composition are entirely his own.
" Every applicant for an examination of this kind is required,
of course, to fill out the application form containing information required of all applicants for appointment to the classified service as
set forth in the civil service law and rules. In addition, the Commission has prepared and printed a separate form containing questions, which the applicant is required to answer under oath, on his
education, training and experience, and instructions as to the preparation of a thesis or the submission of publications. The applicant
is also required to furnish the names and addresses of persons or institutions having a knowledge of his educational and special qualifications, to whom may be addressed confidential inquiries with a view
to corroboration of his statements with respect to his education, training and experience.
*           *           *           *           *           *
"The results of examinations of the nonassembled type have
been eminently satisfactory. No difficulty has been experienced in
ascertaining by this means the relative value of the qualifications of
the applicants for any positions to which this type of examination
has been applied. The Departments, too, have expressed great satisfaction with the material obtained."




70


ACKNOWLEDGMENT.
In conclusion, thanks are due not only to those mentioned in the letter
transmitting this report, but also to the following for most effective cooperation:
Mr. H. S. Gilbertson, Secretary Short Ballot Organization.
Dr. Charles Norris, Director of Laboratories, Bellevue Hospital.
Dr. Douglas Symmers, Professor of Pathology, Bellevue Medical
College.
Dr. Horst Oertel, Lecturer in Pathology, McGill University, Toronto.
Dr. George B. Magrath, Medical Examiner, Suffolk County, Boston,
Mass.
Messrs. Lucian S. Breckenridge and Deacon Murphy, Deputy Assistant
District Attorneys, New York County.
In the Appendix is included interesting and valuable testimony from
Coroner Feinberg, President of the Manhattan Board; from Coroners Healy
(Bronx) and Vail (Richmond); and from Chief Clerk Austin (Bronx).
Respectfully submitted,
LEONARD M. WALLSTEIN,
Commissioner of Accounts.
Jan. 2, 1915.




APPENDIX.
TABLE SHOWING OCCUPATION OF CORONERS PRIOR TO ELECTION TO OFFICE; OTHER OCCUPATIONS DURING INCUMBENCY OF OFFICE, AND OCCUPATIONS AFTER EXPIRATION OF TERM OF OFFICE
MANHATTAN


Term
Coroner.          of Office.
Theo. K. Tuthill.......1897
William H. Dobbs.....1897
Emil E. Hoeber.......1897
Edw. T. Fitzpatrick.... 1897-1901
Antonio Zucca........1898-1901
*Jacob E. Bausch....... 1898-1901
E. W. Hart............ 1898-1901
Nicholas T. Brown....1902-1905
Solomon Goldencranz.. 1902-1905
tMoses J. Jackson......1902-1905
Gustave Scholer......1902-1906
P. P. Acritelli.........1907-1909
Peter Dooley.........1907-1909
Julius Harburger.....1907-1909
Geo. F. Shrady........1907-1909
Jas. E. Winterbottom..1910-1913
Henry W. Holzhauser.1910-1913
I. L. Feinberg.........1910-1917
Herman Hellenstein.... 1910-1917
Timothy P. Healy.....1914-1917
Patrick D. Riordan....1914-1917


Occupation Prior to
Election to Office of Coroner.
Physician...........................
Real estate and builder..............
Physician...........................
Excise Commissioner...............
Dealer in fruit and Italian products..
Wood carver......................
Employed in Fire Dept. repair shop.
Later City Excise Inspector........
Shoe business, member Board of
Aldermen.........................
Physician..........................
Physician...........................
Physician...........................
Banker.............................
Plum ber...........................
Public office-holder for forty years..
Physician, Health Department.......
Undertaker.........................
M arble  cutter......................
Physician..........................
Physician...........................
Business Agent, Executive Firemen's
Union,  Local  6....................
Physician...........................


Other Occupation During
Incumbency of
Office of Coroner.
Physician.....................
Real estate and builder........
Physician.....................
None.........................
Dealer in Italian products.....
Saloon  business...............


Occupation After
Expiration of Term of Office.
Physician.
Not known.
Physician.
Not known.
Dealer in olive oils.
Manufacturer of tables.


None......................... Clerk, Marriage License Bureau.


Real estate...................
Physician.....................
Physician.....................
Physician.....................
Banker.......................
None.........................
None.........................
Physician.....................
Undertaker...................
None.........................
Physician....................
Physician.....................
National President, State Firemen's Union................
Physician.....................


Real estate.
Deputy Tax Commissioner.
Physician.
Physician.
Auto supplies, real estate, clerk
at House of Representatives,
Washington.
Public office-holder.
Supt. of Aqueduct Police.
Undertaker.
Real estate agent.


* Member Board of Assessors, 1904-1910.
t Indicted for bribery, January 5, 1905; indicted for bribery, January 24, 1905; convicted of bribery, February 22, 1905.




TABLE SHOWING OCCUPATION OF CORONERS PRIOR TO ELECTION TO OFFICE; OTHER OCCUPATIONS DURING INCUMBENCY OF OFFICE, AND OCCUPATIONS AFTER EXPIRATION OF TERM OF OFFICE
BRONX
Other Occupation During
Term             Occupation Prior to                  Incumbency of                  Occupation After
Coroner.         of Office.    Election to Office of Coroner.          Office of Coroner.         Expiration of Term of Office.
Anthony McOwen.... 1898-1901    Clerk of Court, Tax Commissioner... None......................... None.
Thomas M. Lynch.....1898-1901    Port Warden....................... None......................... Water Register.
Wm. J. O'Connor, Jr..1902-1905 Real estate......................... Real estate and music publisher. Real estate.
Joseph I. Berry.......1902-1905 Lawyer............................. Lawyer....................... Park Commissioner and Deputy
State Tax Commissioner.
Robert F. McDonald... 1906-1909 Surgeon............................ Surgeon...................... Surgeon.
*A. F. Schwannecke.... 1906-1912                                       Held position in Excise Dept...
Jacob  Shongut.......  1910-1913  Auctioneer.........................  Auctioneer....................  Auctioneer.
Jerome  F.  Healy......1910-1917  Printer.............................  None.........................
W m.  J.  Flynn.........1914-1917  Plumber............................  Plumber......................
* Killed in performance of duty.
TABLE SHOWING OCCUPATION OF CORONERS PRIOR TO ELECTION TO OFFICE; OTHER OCCUPATIONS DURING INCUMBENCY OF OFFICE, AND OCCUPATIONS AFTER EXPIRATION OF Tl-RM OF OFFICE
BROOKLYN
Other Occupation During
Term             Occupation Prior to                  Incumbency of                  Occupation After
Coroner.         of Office.    Election to Office of Coroner.          Office of Coroner.         Expiration of Term of Office.
*Edw.  B.  Coombs......1897     Politician...........................  Politician.....................  Politician.
tGeorge H. Nason......1897        Undertaker's assistant.............. Undertaker................... Clerk in the Assembly.
G.  W.  Delnap........1898-1901  Physician...........................  Physician.....................  Physician.
A.  J.  Burger.........1898-1901  Physician...........................  Physician.....................  Physician.
M. J. Flaherty........1902-1905  M usician,  Sheriff...................  None.........................
P. T. Williams....... 1902-1905 Milk business...................... None......................... Deputy Register of Brooklyn.
H. J. Brewer.........1906-1909  Physician...........................  Physician.....................  Physician.
J. F. Kennedy.........1906-1909  Real estate and insurance............ Insurance..................... Real estate and insurance.
Ed. Glennen..........1910-1913 Undertaker......................... Undertaker................... Undertaker.
A. J. Rooney..........1910-1913  Physician...........................  Physician.....................  Physician.
F.  S.  Senior...........1914-1917  Physician...........................  Physician.....................
C.  E.  W agner.........1914-1917  Contractor.........................  None.........................
* Convicted of grand larceny, 1898.
t Indicted for grand larceny. December 3, 1897; indictment dismissed January 10, 1898.




TABLE SHOWING OCCUPATION OF CORONERS PRIOR TO ELECTION TO OFFICE; OTIER OCCUPATIONS DURING INCUMBENCY OF OFFICE, AND OCCUPATIONS AFTER EXPIRATION OF TERM OF OFFICE
QUEENS
Other Occupation During
Term             Occupation Prior to                  Incumbency of                  Occupation After
Coroner.         of Office.    Election to Office of Coroner.           Office of Coroner.        Expiration of Term of Office.
B.  G.  Strong..........1897-1898  Physician...........................  Physician.....................  Coroner's  physician.
Lawrence Wise..... 1898         Bricklayer.......................... Saloon-keeper................ Saloon-keeper.
Philip  Cronin.........1898-1901  Carpenter..........................  Politics.......................  Real estate.
Ira M. Clapp..........1898       Detective, New York banking house.. None......................... None.
E. D.  Skinner.........1898      Not known.........................  Not known...................  Not known.
John Mann..........1898         Not known......................... Not known................... Not known.
Leonard Rouff........1898-1905    drtaker........................   Undertaker................... Undertaker.
*Samuel  S.  Gray,  Jr.... 1899-1901  Dentist.............................  Dentist.......................
S.  D.  Nutt............1902-1909  Physician...........................  Physician.....................  Physician.
Alfred  S. Ambler..... 1907-1912  Physician...........................  Physician.....................  Physician.
G. J. Schaefer.........1910-1913  Express and van business............ Express and van business...... Express business.
D.  M.  Ebert...........1914-1917  Painter............................  Paint  store...................
Carl Vogel...........1914-1917 Assistant Secretary of State and Chief
Clerk, Bureau  of  Elections.........  Politics.......................
* October 7, 1907, sentenced to 14 years and 10 months in Sing Sing for manslaughter.
TABLE SHOWING OCCUPATION OF CORONERS PRIOR TO ELECTION TO OFFICE; OTHER OCCUPATIONS DURING INCUMBENCY OF OFFICE, AND OCCUPATIONS AFTER EXPIRATION OF TERM OF OFFICE
RICH MOND
Other Occupation During
Term             Occupation Prior to                  Incumbency of                  Occupation After
Coroner.         of Office.    Election to Office of Coroner.           Office of Coroner.        Expiration of Term of Office.
James W. Bedell........1897       Undertaker......................... Undertaker................... Undertaker.
John  T. Oates.......... 1897     Undertaker.........................  Undertaker...................  Undertaker.
Isaac  A.  Silvie.........1897    Undertaker.........................  Undertaker...................  Undertaker.
C.  W.  Townsend.......1897     Physician...........................  Physician..................... Physician.
George C. Trarton......1898-1901 U. S. Custom House Inspector....... None....................... Postmaster, Richmond.
John Seaver...........1898-1901 Real estate......................... Real estate................... Employed in Topographical
Bureau, Richmond.
Geo. F. Schaefer.......1902-1905  Undertaker, at one time in Dept. of Undertaker................... Attendant, Bureau Public BuildSt. Cleaning, also Docks and Ferries                                 ings and Offices.
Matt. J. Cahill..........1906-1909  Butcher.............................  None.........................  Deputy  Tax  Commissioner.
Wm. H. Jackson........1910-1913 Real estate, newspaper owner........ Real estate................... Real estate, newspaper owner.
J. L. Vail.............1914-1917 Clerk, Broker's office................ None........................
-    --                                 — ~~~~~~~~~~~~~~~~~~~~~~~~~~~~..




STATEMENT OF DIRECT EXPENSES OF CORONERS' OFFICE IN NEW YORK CITY, BY BOROUGHS AND BY YEARS, 1910 TO JULY 31, 1914.
Total
Total     No. of
Expense    Deaths   Cost
1910.            1911.            1912.              1913.          1914 to July 31.   Jan. 1,   Jan. 1,  Per
r   x            AA ---, ---,- -    -     -A r                                     1910, to  1910, to  Case.
Total   Total    Total   Total   Total    Total      Total     Total    Total     Total   July 31,  July 31,
Expense. Deaths. Expense. Deaths. Expense. Deaths.   Expense.  Deaths. Expense.   Deaths.    1914.     1914.


- _g


M
Bi
B1
Q
R


[anhattan...$70,949 35 5,408
ronx........   32,135 93    897
rooklyn.....     36,390 41 3,260
ueens.......     19,667 44    659
ichmond....    12,868 32    245
Totals...... $172,011 4510,469
ost per case..             $16 43


$69,124 81 5,701
32,784 21  998
38,584 76 3,241
19,487 14  715
13,068 97  262
$173,049 89 10,917
$15 85


$68,949 00 5,697
32,171 06 1,021
38,309 53 3,258
20,379 87  746
12,853 73  271
$172,663 19 10,993
$15 71


$68,878 54
33,169 26
38,450 80
20,245 75
12,861 66
$173,606 01


5,750
1,070
3,152
823
330
11,125
$15 61


$42,996 87
19,039 08
19,050 52
12,038 43
7,573 24
$100,698 14


3,825
643
2,005
468
202
7,143
$14 10


$320,898 57
149,299 54
170,786 02
91,818 63
59,225 92
$792,028 68


26,381
4,629
14,916
3,411
1,310
50,647
$15 64


$12 16 
32 25
11 47
26 92
45 21


Cc




75


CORONER FEINBERG'S STATEMENT.
I realize that the Coroners' system as now constituted is not only inadequate but subject to great abuses. The Coroners' prime function is to
accurately ascertain the cause of death in certain classes of cases. There
is no question of governmental policy involved, but the mere question of
accurate, painstaking, expert work. No layman can properly perform this
prime function of a Coroner. The doctor of ordinary household practice
is not qualified for it either. It requires special preparation, special training, and special aptitude.
Any system which attempts to secure these qualifications through choice
by popular election is bound to fail. Popular election is, as we all know,
not only an excellent but the only method of insuring that those who make
the policies of the government shall represent the spirit of the people, but
the public ill-serves itself when it attempts by popular election to choose
specially qualified persons for specially difficult positions of a scientific character, concerning the details of which there can be no adequate popular
knowledge as to the individual's qualifications.
It is a fact to-day that the ascertainment of the cause of death is not
efficiently performed in a great number of cases. It is a fact that the
average lay Coroner is unable to pass intelligently upon the medical work of
his Coroner's physician, nor to pass properly upon the legal questions which
arise in connection with the Coroner's work. It is a fact that the salary paid
to the lay Coroners and to unnecesary subordinates makes it impossible to
pay adequate salaries to properly qualified men charged with the medical
side of the work and militates against the employment of such men under
the present system.
It is a fact that the lack of any central control over the work of the
Coroners' Office produces waste and confusion and inefficiency. It is a
fact that the jury system in the Coroners' Court is obsolete, practically useless, and subject to great possible abuse under given conditions. It is a fact
that the Coroners' system fails to present adequate medical information in
non-criminal cases, which information is of great importance to the accuracy
of the vital statistics of the community. It is a fact that on the whole the
medical work done under the present system is not sufficiently accurate to
satisfy the legitimate requirements in both criminal and civil cases.
It is a fact that various District Attorneys have felt it incumbent in
criminal cases to duplicate to a greater or lesser extent the work of the Coroners' Office. I believe that this duplication of work by District Attorneys
has been due to their conviction, not unfounded, that the present Coroners'
system is inadequate.
The Coroners' function is peculiar in so far as he deals with hundreds
of isolated cases which come to the knowledge only of the family immediately concerned, and possibly of the criminal authorities. It is therefore
highly important that the performance of this function should be subjected
to the centralized control which I have previously mentioned and to constant




76


supervision and investigation by responsible authority. It is true that due to
the absence of any such machinery in the present system, the individual Coroners have worked abuses upon the families in individual instances.
For instance there is a well-grounded suspicion that individual Coroners
have foisted favored undertakers upon the families of deceased persons;
that these undertakers have charged exorbitant fees; that the ability of
the Coroner thus to abuse his special authority has been due to threats of
sending bodies to the morgue or of professed inability to issue removal
permits under certain circumstances.
Another characteristic of the present Coroners' system, inevitable from
the lack of technical training in the men who have manned it, has been the
complete absence of co-operation between the Coroners' Office and the
great body of medico-legal pathologists available in this community. Abroad
there is the very closest co-operation between the official body charged with
the function which the Coroners here are intended to serve and such
medico-legal experts. That co-operation should also exist in this city and
I am convinced that the reconstruction of the present system, which I
shall hereafter mention, will go far toward bringing about that very highly
desirable co-operation that I have mentioned.
In passing, it should be mentioned that on the judicial side the present
system is subject, among other defects, to much abuse and lends itself
readily to great inefficiency by reason of the fact that there is no clear
and well-defined rule as to how far, if at all, the principles of legal evidence
are to be applied in proceedings before a coroner and his jury. The
result of this has been that in some instances the jury has discharged
defendants by reason of having placed before them evidence which upon
all legal principles was inadmissible.
I should state in addition that the law which governs the Coroners'
Office, scattered as it is through various statutes and apparently conflicting
as it is on some points, and really conflicting as it is on other points, has made
it difficult even for properly qualified officials to administer the law. Certainly the confusion in the law to which I have referred has made it easy
and has afforded opportunity to abuse the powers of the office.
In brief, the fundamental defect in the present system is the attempted
combination in the Coroners of an adequate medical examiner, of a legal
investigator and of a competent judicial officer. That combination is so
rarely found that any system which depends for its success upon their
constant presence is bound to fail. The medical work, the legal work and
the judicial work which by the present system are placed upon the Coroner
would each be improved by being separated and made the functions of
separate public officers, each trained for the performance of his function.
I have recently re-examined with great care the bill which was introduced in the Assembly during the session of 1914, entitled
" An Act to amend the Greater New York Charter, creating the
office of chief medical examiner, deputy chief medical examiner, and




77


assistant medical examiners, prescribing their powers and duties,
abolishing the office of the Coroner and repealing one section of
chapter 410 of the laws of 1882 in relation to Coroners."
After such re-examination and consideration, I believe that the enactment of this law would accomplish a vast improvement upon the present
system.
I favor the abolition of the present Coroners' system, and the establishing of an efficient department of medical examination generally as outlined
in this legislation with some exceptions as to detail. I shall do all that I
can to aid in the enactment of this legislation, believing it to be for the
best interests of the public.
The claim that the proposed new system will unduly increase the
number of autopsies, on due reflection, I believe to be much exaggerated.
The proposed bill contains ample safeguard against such abuse.
Some little change should be made in the bill as to the length of
experience required of the chief medical examiner, his knowledge of pathology and microscopy, and his general knowledge of death cases as a whole,
so that the field shall be open to as large a number of men as may be
qualified.
CORONER HEALY'S STATEMENT.
New York, December 9, 1914.
LEONARD M. WALLSTEIN, Esq.,
Commissioner of Accounts,
Municipal Building, New York City:
DEAR SIR-In connection with the investigation upon which you are engaged at the Mayor's direction of the Coroners' office of New York City,
I desire to make the following statement of facts and the following expression of my opinions for your record:
I have been a Coroner of The City of New York for the Borough of The
Bronx since July 10, 1912, having been appointed on that date by Governor
Dix to fill the vacancy caused by the death of the late Coroner Schwannecke,
and having been elected for the term of one year in November, 1912, and
again for the full term in November, 1913.
During my term of office I have discharged the duties of the office to
the best of my ability, and believe that your investigation will verify my
statement that whatever errors or insufficiencies may be found in my administration they have never been due to any desire personally to profit by
my office, or otherwise to prostitute the powers of my office. At the same
time I do wish to make perfectly clear to you my opinion, based upon my
experience in the office, that the present Coroners' system is entirely inadequate for the discharge of the functions which are by law imposed upon the
Coroners.




78


In the first place, it is difficult to conceive how it could be reasonably expected that one man, elected as he is under the present system upon a ballot
all too long for the proper examination of the qualifications of the candidates
by the voters, can be expected in himself to embody all the technical training
that is necessary for the competent discharge of the medical, the legal and
judicial functions imposed upon the Coroner. It is, of course, true that
the fundamentals of popular government require that officials shall be elected
by the People, and generally speaking that is one of the tenets of my political
faith.  It must be kept in mind, however, that where expert technical
service and technical qualifications, based upon technical training, are required, that in such instances the people ill-serve themselves when they attempt to choose that kind of official by popular election. Thus, it would be
futile to endeavor to elect a Health Commissioner by popular election, or a
Highway Engineer by popular election, or a Quarantine Officer by popular
election. In short, the requirements of popular rule are that the People shall
elect the policy formulators of their government, but it does not require
that they should elect officials who are charged merely with the administration of technical branches of the government. To my mind, the duties which
are imposed upon the Coroners under the present system call for the same
technical training, and yet one of the fatal defects in the system is that there
is no requirement of such technical training as a prerequisite to eligibility to
the office. In short, it is my opinion that the three-fold functions of the
Coroners which I have enumerated should be separated, and each discharged
by a man who has the technical qualifications which are required for the
efficient performance of the duties of the office. In other words, the judicial
aspects of the Coroners' functions should be performed by magistrates or
trained lawyers, and the medical functions by specialists in legal medicine,
such as I believe the Coroner's phyrsiciaIls of The Bronx, Doctors Riegelman
and Curtin, to be. Certainly it is clear to me that under any adequate system
no layman, however conscientiously he may try and however single-purposed he may be in his devotion to the public's interest, can administer the
office as now constituted with the efficiency which the important functions
of the office call for. His intentions may be of the best, as mine have been,
but the results inevitably, without fault upon the individual, fall short of
what the public have a right to demand.
Among other things which under the present system tend to handicap the
well-intentioned Coroner in the performance of his duties, is the lamentable
confusion in the law. The criminal code contains certain requirements; the
consolidation act prescribes others. It is not always easy to ascertain which
of these provisions of law applies to a given case. I can readily understand,
therefore, how unscrupulous individuals in office could, if they were so disposed, take advantage of this confusion, real or apparent, to prostitute the
powers of the office.
Another weakness in the present system is the entire absence of central
control over the work of the Coroners' Office throughout the city. To my




79


mind the efficiency of the service would be much increased if there were for
the entire City of New York a central individual vested with the direction
of the work of medical examination throughout the city.
To my mind also the jury system in the Coroners' Court is obsolete.
City Magistrates who, like the Coroners, are in cases of felony vested only
with the power to determine whether there is probable cause to believe a
defendant guilty of the crime, and who are, as are the Coroners, not empowered to pass final judgment, do not have juries, and the system of our
Magistrates has never been criticised by reason of the absence of juries.
Indeed, the elimination of the jury tends to concentrate responsibility where
it belongs. Moreover, I can well see how, with a jury to divide responsibility with him, an unscrupulous individual holding the office of Coroner
might, especially in view of the absence of provisions governing the selection of the jury, use the jury for purposes contrary to law and the proper
administration of justice. In this connection I should have stated that
with all the facilities that the present law obviously offers to an unscrupulous official, personally I have never interested myself in the questions of
who shall or should be on a jury, and have accepted my juries as they appeared in the jury-box in my court-room.
The fact must not be overlooked that the Coroners' Office has an important, though often not realized, bearing upon the work of the Health Department of this city. Many of the cases which the Coroners' Office under
the present system handles have to do purely with natural-cause deaths, in
which no question of criminality is involved. In that connection the cases
that come within the jurisdiction of the Coroner should be examined on the
medical side solely for the purpose of accurately ascertaining the cause of
death, so that the statistics thus gathered may enter into the body of statistics compiled by the Health Department for its use in the administration of
that department on the preventive side. Particularly, is it important that
instances of infectious, communicable and venereal disease should be accurately ascertained, and the facts thereof made known to the Health Department officials. This, of course, is purely technical medical work, in connection with which the Coroner as such has no real usefulness. By this I
do not mean to convey the idea that there should be too many or indiscriminate autopsies. That, however, is a matter of administration, and can
readily be avoided under any system.
I have read the bill which was introduced by Assemblyman Brennan at
the last session of the legislature for the purpose of reconstructing the Coroners' system in New York City, and desire hereby to signify my approval
of that bill. I believe that it makes proper and adequate and much improved
provision for the efficient performance of the functions now imposed upon
the Coroners, and believe that, in its provision, that the present Coroners
should hold their office for the term for which they were elected, it insures
that officials as to whom there is no proof of individual misconduct shall
not be personally penalized for the inadequacies of the present system.




80


With this expression of my views, and with my promise to you that I
shall lend my earnest support for the enactment of such a bill, permit me
to remain.
Very truly yours,
(Sgd.)  JEROME F. HEALY.
P. S.-I trust that, as stated in the beginning of this letter, you will
make it part of your public record of the examination into the Coroners'
office.
CHIEF CLERK AUSTIN'S STATEMENT.
Coroner's Office,
Borough of The Bronx,
1932 Arthur Avenue, Corner Tremont Avenue.
New York, December 10, 1914.
Jerome F. Healy,
Wm. J. Flynn,
Coroners.
Wm. T. Austin,,
Chief Clerk.
Hon. LEONARD M. WALLSTEIN,
Commissioner of Accounts,
Municipal Building, New York.
SIR-I have been connected with the office of the Coroners of The
Bronx as Chief Clerk since January, 1906. During this time I have observed the weaknesses of the present system and the possibilities for corruption, which have been emphasized by your investigation. I desire to
submit my opinion, based on my experience and observation.
It is my belief that the present system of Coroners should be abolished.
It is absurd to expect a layman, elected on the long ballot, to combine the
efficient performance of the legal, medical and judicial functions that the
present system demands. I believe that these functions would be more
efficiently and satisfactorily performed by men specially trained in each line
of activity, and that the new system should provide for the separation of
these functions. The medical examinations should be under central control
of the City, and should be performed by men specially trained in legal medicine-such as I believe Doctors Curtin and Riegelman of this office to be.
The system should also provide for the establishment of laboratories to assist the medical men in the performance of their duties. The legal functions should be performed by men trained in law and could be satisfactorily




81


taken over by the District Attorney's office, while the judicial functions
should be performed by the Magistrates.
The law governing the administration of the Coroners' office is conflicting and ambiguous in many respects and lends itself to malfeasance and
corruption, if the officers are so inclined.
The jury system is obsolete and by reason of the division of responsibility makes it possible for a Coroner to prostitute the powers of his office.
I wish to state, however, that so far as the personnel of this office is concerned, the Coroners, the physicians and the other attaches have performed
their duties honestly and with the best intentions, and that if there have
been any delinquencies or shortcomings, these were due to the present system rather than to any intent on the part of any individual to violate the law.
I have read Assemblyman Brennan's bill and will support it when introduced
at the next legislature. If a new system be established, I trust that the men
who have been found faithful to their trust and conscientious in the performance of their duties will receive consideration.
Respectfully,
(Signed)      WILLIAM T. AUSTIN,
Chief Clerk.
CORONER VAIL'S STATEMENT.       ~
Coroners' Office, City of New York, Borough of Richmond.
New Brighton, N. Y., December 14, 1914.
Hon. LEONARD M. WALLSTEIN,
Commissioner of Accounts,
Municipal Building, New York City:
SIR-In compliance with the request of your representative I desire to
submit my views with reference to the present Coroners' situation.
I was elected to the office in November, 1913. During my incumbency
I have endeavored to perform my duties conscientiously. My experience,
however, has taught me that the present law governing the conduct of the
Coroners' office is somewhat confusing and vague, and should your investigation show that there have been any omissions in the performance of the
duties of any attache of the Coroner's office of this Borough they are due to
the present system of Coroners rather than to the desire on the part of any
individual to violate the law. We have performed our duties as we saw
them.
In Richmond, while the amount of business is not so great as in the
other Boroughs, due perhaps to its being more of a suburban community and
free from the undesirable element, the distances to be covered are greater
and the facilities for transportation are very poor, particularly at night.
I agree with you that the present Coroners' system demands the com



82


bined qualifications of legal, medical and judicial knowledge and it is therefore unreasonable to expect the average layman to perform these functions
satisfactorily, and there is no doubt in my mind that the separation of these
functions would greatly improve the conditions as they now exist.
I am also of the opinion that it would be a good idea to have the medical
examinations under the central control of the City in charge of men not
only expert in legal medicine but also of the highest character procurable,
as I feel that indiscriminate autopsies would be a menace to the community.
While it is the present custom in this Borough for the District Attorney to co-operate with this office in all cases requiring his attention, and
I have always made a personal investigation independent of his, that the ends
of justice might possibly be further served, nevertheless I am of the opinion
that with the assistance of the police, the district attorney could conduct investigations of cases of possible commission of crime without assistance from
any Coroner's office while the limited powers as at present invested in the
Coroners remain as they are.
I also believe that if no remedial legislation can be obtained in regard
the present powers and conduct of the Coroner's office and the abolition of
the present system is decided upon, a transfer of the judicial functions to the
Magistrates would make for efficiency.
Regarding the present jury system, when one considers the great difficulties experienced by the Coroner's office in obtaining reputable and efficient jurors because of non-compensation for services and the limited powers
of the Coroner regarding punishment of jurors who fail to respond to a summons, I have never been able to see the necessity for same, and also by
reason of the divided responsibility it is possible for a corrupt Coroner to
prostitute the powers of his office, if he is so inclined.
Although it is my opinion that reforms should be made in the present
system of Coroners, as a Democrat I contend that inasmuch as the Coroners
have been elected by the people for a term of four years those Coroners who
have been found faithful in the performance of their duties should be permitted to serve out the balance of their terms.
In justice to the staff of my office I wish to state that I have always
found they have performed their duties honestly, conscientiously and with
the best intention, and I therefore contend further that, in the event of the
abolition of the present system, provision should be made for the retention
of these men in the service of the City of New York, as by their length of
service they have acquired much valuable experience, preference being
given in regard to seniority in the service of the City of New York.
I have read the Brennan bill and will support it when it is next introduced in the legislature in so far as I have herein set forth my opinions.
Very truly yours,
(Signed) JAMES L. VAIL.
















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