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VI. The Coroner

A Historical Sketch



 Medieval depiction of an Autopsy

Coroners Adelbert Facility 1954

The specialized field in which the skills of medical science are applied to serve the needs of law and justice is called legal or forensic medicine.

Legal medicine is so intimately associated with human conduct that its development may be considered contemporary with that of the social development of man, and particularly with the recognition or punishment of crime. Biblical laws made a distinction between moral and dangerous wounds and had law relating to subject of public medicine. The laws of ancient Greece and Rome demonstrated evidence that some of the more important medico-legal problems were recognized. Suetonius recorded that the body of Julius Ceasar was examined by a physician named Antisius, who declared that out of 23 wounds inflicted, the one which penetrated the thorax was the cause of death.


 Anatomy Lesson of Dr. Nicolaes Tulb by Rembrandt

The Justinian Code (529-533 A.D.) required the opinion of a physician in certain cases and is often credited as the origin of recognition of the correlation of law and medicine in effecting legal justice. In a penal code formulated by the Bishop of Bamberg in 1507 A.D., it was stipulated that a medical examination was to be made in all cases of violent death. In 1532, the Diet of Ratisbon under Charles V designated in the Constitution Carolina that in all cases where medical testimony could enlighten the judge or assist in the investigation of personal injury or murder, such evidence was to be required. Thus, on the European continent the specialty of legal medicine developed as a specific function of government.

In England and Ireland at that time, we find a somewhat different approach to the legal problems of criminal violence. There the investigations were made by a representative of the King. The full title of this official was: "Custo Placitorum Coronae, more popular the "Coronator". Eventually this title became Coroner. The exact date of the origin of this office in England is not known. Some believe that it originated under the Saxon Kings, perhaps as early as 958 A.D. Other dates of origin are presumed to be "soon after the conquest by William the Conqueror" (1066 A.D.) or "under Henry the First" (early in the twelfth century). Article 20 of the Articles of Eyre (1194) provided for the election of one clerk to act as custodian of the pleas of the Crown. His relation to death by violence was secondary to other functions. When death resulted from violence, it was customary to seize the property of the victim.

Objects producing accidental death were confiscated also. These were sold, and the receipts distributed as alms. It was supposed to mean of appeasing God's wrath the shedding of blood.

It is believed that William Penn, founder and Governor of Pennsylvania, appointed the first coroner in American colonies. This appointment was made when a dead body was found on the bank of a river in Pennsylvania. The coroner was instructed to investigate the facts concerning the death, proceeding in the same manner as was customary in England except that the property of the dead man was to be held in trust for the heirs.

The Coroner in Ohio

An ordinance of Northwest Territory in 1788 provided for the appointment of a coroner for each county to serve a term of two years. Such appointment was to be made by the Governor. The duties of the coroner included holding inquests over the bodies of all persons found within the county who were believed to have died by criminal violence or casually. He was also to have the same power as a sheriff.

The Constitution of the State of Ohio enacted in 1802 provided that a coroner should be elected in each county to serve for a term of two years. A statute enacted in 1805 started the duties and authority of the coroner and provided for remuneration on a fee basis. In 1831 state legislation directed the coroner to return a report of his findings in an inquest to the clerk of Courts of Common Pleas. (Reports of such cases dated from October 20, 1833 are on file in the Cuyahoga County Coroner's Office.)

The first administrative county officers elected in the County of Cuyahoga were: The County Commissioners, the Sheriff, and the Coroner. They were inaugurated on May 1, 1810.

Constitutional changes of 1851 and 1912 did not affect the office of the coroner. It was not until 1921 that the coroner was empowered to perform autopsies and then only upon authorization by the county prosecutor. In the same act, the coroner was granted discretionary power toward holding formal inquests, and he was directed to investigate deaths supposed to have been caused by unlawful or suspicious means. In the same year, a bill was enacted requiring that in counties with a population of one hundred thousand or more, no person should be eligible for election to the office of coroner except a physician of good standing in his profession. In 1973, the same qualifications for eligibility were established for coroner in all Ohio counties. In 1936, the term of office was increased to four years. In 1945, by act of legislature, the statutes governing the office of coroner were revised to the extent that the Ohio law in this respect is now example for providing modern medicolegal investigation in a democracy. Some of these revisions include: specific definitions of duties and authority; remuneration by salary rather than fees for all coroners; authorizing a plan whereby coroners in counties without established pathological service may obtain same from counties with such facilities at a fee commensurate with the actual cost of time and materials used.


The Coroner and Medicolegal Investigation

The Coroner is charged by law with the responsibility of determining the cause, mode, and manner of death. The determination of the anatomic cause of death is a medical aspect while the legal interest is all-inclusive and requires that all factors of causation, the mode and manner, as well as the interrelated that they cannot be separated; therefore equal consideration must be given to the medical and legal phases of investigation. This requires a specialized discipline correlating knowledge of law and medicine in a medicolegal investigation.

As an illustration, consider a medical examination performed merely to determine the anatomic cause of death. In such a case it would be sufficient to establish that a penetrating wound in the heart was the immediate cause of death. However, to determine the mode of death it would be necessary to establish whether that wound was caused by a bullet or a sharp instrument. A though autopsy for medicolegal purposes would reveal evidence to make this determination. The next question of legal importance is the manner of death; in other words, how was this wound inflicted or sustained? Was it self-inflicted? If so, was it intentional-that is to say, suicide- or was it accidental? If inflicted by another person, was it accidental or was it homicide? Investigation of the scene where the injury was sustained, examination of the evidence found there and statements of witnesses would furnish information as to the circumstances of the incident. Examination of the clothing of the victim as well as through study of the body would yield evidence, which could be used to test the reliability of the conclusions based on investigation of the scene and interrogation of witnesses.

The above illustration is a general example of one type of case where investigations must be correlated in order to arrive at a just decision. In other instances, if may be necessary to acquire information from an attending physician, hospital records, and those acquainted with the decedent. The police, other investigative agencies, and the coroner must work in close cooperation with one another.