The first formal mention we have of the ‘coroner’ is in 1194 in the Articles of Eyre. In medieval England, itinerant justices traveled the countryside along the ‘Eyre’ (the judicial circuit) inspecting villages, holding court, settling disputes, and levying fines. This process was called “holding the pleas of the crown.” By 1194, the process had become grossly inefficient and prone to abuse. Justices took years to complete their circuit, during which time villages were at the mercy of the county sheriff, who grew fat squeezing the peasants without kicking much up to the king. This was a particular problem for Richard I (Richard the Lion-Hearted) who desperately needed money to finance his crusades, wars in France, and (once) his own ransom.
Enter Walter Hubert, legendary bureaucrat and architect of the 1194 Articles, which, among other reforms set up a new cadre of county officers tasked with ‘keeping the pleas of the crown’ (custos placitorum coronae). The new coroners (or ‘Crowners’ as they were called for centuries) did not hold court but rather documented the claims the king could make when finally his court rolled into town. The duties of the new office were highly varied, but the charge was simple: generate revenue by promoting the king’s rights and interests. When someone found buried treasure? It belonged to the king. When something of value washed ashore after a shipwreck? It belonged to the king. When someone stole from the royal fisheries? The coroner documented it and made sure not only that fines were paid but that all such revenue made it to the royal treasury.
From the very beginning coroners took particular interest in sudden deaths because they represented potential windfalls for the crown. Where the coroner suspected homicide or suicide, the crown could claim the perpetrator’s estate. In the case of accidents, objects associated with the death could be seized and sold or given to the church as a “deodand” - an appeasement to God. Then there were the myriad petty fines. According to law, the “first finder” of a dead body was required to raise the “hue-and-cry,” assemble a posse to hunt for suspects, and notify local officials, who in turn notified the coroner. Meanwhile the body had to rest undisturbed until the coroner could arrive to see if the king could turn a profit in the Reaper’s wake. Every failure to follow protocol resulted in a fine (which incentivized peasants to drag bodies to different jurisdictions or hide them altogether). In such cases, the coroner fined the whole village. Thus, when a dead Norman was found on a village commons (which evidently happened a lot), the Crowner levied a fine called the "Murdrum," from which the word murder derives.
Gradually, a basic division of labor emerged between coroner and sheriff. The sheriff kept the peace among the living; the coroner kept the crown’s pleas against the dead. Thus, the sheriff comes down to us through English literature as a local tyrant. (Think of the Sheriff of Nottingham in the Robin Hood mythos.) And the coroner comes down to us as the representative of a distant, rapacious state. Thus in Hamlet does the gravedigger complain that a rich suicide has gotten a Christian burial because the “great folk” have paid off the ‘Crowner’ and are allowed to “drown or hang themselves” as they see fit. (“Come, my spade,” he concludes, the only real gentlemen are the “gardeners, ditchers, and grave-makers.”)
By the time the coroner came to colonial America, his duties had stabilized around the investigation of untimely deaths. Colonial charters gave the power to appoint coroners to the governor or his council, though the office gradually became elective in certain states and districts. The first election to the position of coroner was held in Plymouth Colony in 1636, but in most states the position remained an appointed one well into the antebellum period. In all states, the coroner was charged with convening an inquest when notified that someone in their jurisdiction (originally walking distance) had “come to his death by violence or suffered an untimely death.” Such inquests, wherever practicable, were to take place “where the body lies" and were to be attended by a specific number of “good and lawful men” (eight in Massachusetts, fourteen in South Carolina) who were under oath to determine “upon a view of the body there lying dead, how, in what manner, and by whom he, or she, came to his or her death.”
Determining “cause of death” is so obviously a medical matter that it may seem strange that coroners typically had no medical training before the twentieth century. The questions aroused by any death go well beyond causation, however, and “untimely death” is especially fraught with implications - legal, religious, and financial. Where homicide is a suspected cause, the community demands justice and order from officials whose authority depends on the “peace and dignity” of the state. Where the deceased had property, assets are now loosed from their legal mooring, touching off waves of litigation (and, in the case of felonies, state seizures). Where the death is dramatic or gruesome, the press longs to feed upon and profit by the public’s macabre taste. And then there are the moral and spiritual dimensions: Every death is a referendum on the life of the deceased and, to varying degrees, on life itself, and the authority of religion often rests on its ability to give meaning to seemingly meaningless death - the sudden, the ghastly, and the tragic.
In the nineteenth century, then, the inquest did more important social work than determining a mere cause of death. Death had opened up a rift in the social fabric, and everyone had an interest to see how or if it would be stitched back up. When we think of our own police force, highway patrol, or FBI, we think of them as ‘law enforcement’ - their job is to make sure everyone is obeying the law. But as historian Laura Edwards has shown, once upon a time, the law had relatively short arms. Laws, yes, were made at the state level, but they weren’t always enforced at the county level. At the county level, the job of the sheriff and the coroner and other local officers was to ‘keep the people’s peace,’ the local understanding of the accepted social order, the sense that what was true yesterday should be true tomorrow. This helps explain why testimony was taken from women and from slaves, as locals they had a stake in what would be true tomorrow and they had information about what was true yesterday. To be sure, the coroner, the doctor, the jurors were all white men, and they would preside as usual over death and pass their judgments. And certainly they were not interested, in the same way we are, in justice. They were interested in something more supple - a satisfactory conclusion.
The coroner was more detective than medical examiner; he inspected the body and (possible crime) scene, interviewed witnesses (including slaves), and sought expert testimony (including from physicians), before discussing the case with a jury that was partially chosen for its knowledge of local personalities and circumstances. And when he had collected his evidence and overseen the jury’s pronouncement, only then did the wheels of the law begin to turn or to remain still. His was the first link in the chain of the legal process. Gradually the coroner would yield some of his duties to other government functionaries, particularly to the police detective and the medical examiner.
The first police department in the United States was formed in Boston in 1838; New York City followed suit in 1845, Chicago in 1851, and New Orleans in 1853. These early units were not created to solve crimes, however, but to police the new urban poor and operate as the enforcers of the rising political machines, capitalists, and captains of industry. In some respects, then, they were a more formalized version of the southern slave patrols, which may explain why the south formed few police departments before the Civil War. Police detectives as we know them, as arms of the criminal justice system, did not emerge until the twentieth century.
The medical examiner, on the other hand, encroached earlier upon duties previously associated with the coroner. While autopsies were relatively rare before the twentieth century, doctors typically functioned as ‘expert witnesses’ at these inquests, called in to perform limited post-mortem examinations and to determine, for instance, if a particular wound was mortal or if a baby had been live at birth. (The ancient practice of “floating” a baby’s lungs to determine if they had drawn breath has been shown to be 98% accurate.) Over the course of the nineteenth century, physicians, for noble reasons and selfish ones, interposed themselves more forcefully into death investigation and the criminal justice system. In 1811, for instance, the physician Benjamin Rush lectured University of Pennsylvania medical students on the potential value of medical testimony in cases of rape, murder, infanticide, and abortion. In 1823, the Beck brothers (Theodric and John) published the two-volume, Elements of Medical Jurisprudence, which became the foundation of modern forensic pathology in the United States. Gradually this pursuit of scientific certainty in death investigation would lead to the weakening and, in some places, the abolishment of the coroner’s office. Boston appointed its first medical examiner in 1877, Cleveland in 1914, and New York City in 1915.
Next time we will look in to the Coroner vs. Medical Examiner systems, which states have which system, and why.
Sources: University of Georgia, Department of History, ehistory