Sudden Deaths in St. Louis: Coroner Bias in the Gilded Age

by Sarah E. Lirley

Overview

Honorable Mention, 2025 Society of Midland Authors Award in History!

A social history of death investigations in the urban Midwest

The scene of myriad grisly deaths, late nineteenth—century St. Louis was a hotbed for homicide, suicide, alcoholism, abortion, and workplace accidents. The role of the city’s Gilded Age coroners has not been fully examined, contextualized, or interrogated until now. Sarah E. Lirley investigates the process in which these outcomes were determined, finding coroners’ rulings were not uniform, but rather varied by who was conducting the inquest. These fascinating case studies explore the lives of the deceased, as well as their families, communities, press coverage of the events, and the coroners themselves.

Sudden Deaths in St. Louis is a study of 120 coroners’ inquests conducted between 1875 and 1885. Each chapter analyzes the typical versus the atypical in verdicts of death. At the time, inaccurate findings and cursory investigations fueled criticisms of coroner’s offices for employing poorly trained laymen. The coroners featured in this book had the power to shape public perception of the deceased, and they often relied on preexisting reputations to determine cause of death. For instance, women who worked as prostitutes were likely to be ruled as suicides, whether or not that was actually the case, and women who were respected members of their communities, particularly mothers, frequently received rulings of suicide caused by insanity. Verdicts also depended in part on availability of witnesses, including family members, to determine whether another person could be held liable for the death. Lirley’s book highlights the stories of ordinary men and women whose lives were tragically cut short, and the injustice they received even after death.

Product Details

ISBN-13:	9780809339327
Publisher:	Southern Illinois University Press
Publication date:	04/12/2024
Edition description:	First Edition
Pages:	190
Product dimensions:	9.00(w) x 6.00(h) x 0.70(d)

About the Author

Sarah E. Lirley is a historian who specializes in the history of women and gender, nineteenth century history, and the history of death and death investigations. Lirley is an assistant professor of history at Columbia College (Columbia, Missouri). She has published articles in the Missouri Historical Review and has written peer—reviewed blog articles, encyclopedia entries, and book reviews in a variety of historical journals. She has presented her research at more than twenty professional conferences.

Read an Excerpt

INTRODUCTION: THE OFFICE OF THE CORONER IN LATE—NINETEENTH—CENTURY ST. LOUIS

J.W. McElvain decided to go fishing with some friends in Cahokia on July 11, 1881, an incredibly hot day.  He and his friends fished for a while, but on the ferry ride back to St. Louis, McElvain complained that he was not feeling well. He felt well enough to walk ahead of his friends once they returned to the city, however, and his friends quickly lost sight of him.  McElvain never made it home. He collapsed on the corner of Eleventh and Lafayette streets, likely because of the oppressive heat that day. A crowd gathered and one man gave McElvain some whiskey while he was lying on the ground—either because he requested it or because this stranger believed that it would help.  McElvain died on that corner soon after collapsing there.

Deputy Coroner Herman Praedicow investigated McElvain’s death and quickly concluded that he died “from the effects of sunstroke,” a verdict that he and Coroner John Frank rendered for dozens of people during a heat wave in July of 1881. But Praedicow made no mention of alcohol use in his verdict, which differed from other men and women who died during the heat wave. Even when they had dozens of heat—related deaths to investigate, coroners distinguished between deaths that were caused by heatstroke alone and those in which illness or alcohol use were contributing factors. The fact that the coroners differentiated between heatstroke and heatstroke exacerbated by alcohol use during a time in which they were overwhelmed with cases illustrates that they based their death investigations and verdicts on factors beyond their own professional standards and medical training, including witness testimony and their own assumptions about race, class, gender, and reputation. In McElvain’s case, a witness told the deputy coroner that the deceased was drinking, but he testified that a man was giving McElvain whiskey, not that he drank of his own accord. No other witness told the coroner that McElvain was a heavy or regular drinker.  The witness testimony likely explains why the deputy coroner did not add “intemperance” to his verdict because in other aspects McElvain was similar to other men and women who received verdicts of heatstroke and intemperance. He was single, working—class, and resided in a boardinghouse—not indicators of a bad reputation, but also not the hallmarks of a respectable, prominent one.

J.W. McElvain’s death is one of 120 coroners’ inquests examined in this study of six types of coroners’ verdicts: deaths from natural causes, alcoholism, suicide, abortion, homicide, and accidental deaths. By interrogating these different categories of coroner’s verdicts to understand how and why coroners made their decisions, it is apparent that verdicts were not uniform, but, rather, varied by coroner. Verdicts were not based solely on the characteristics of the investigation. St. Louis coroners based their investigations and verdicts on several factors: whether or not the deceased had family members to testify in a coroner’s inquest, whether or not another person could be held legally liable for the death, and the reputation and social connections of the deceased. For example, verdicts of suicide reveal that coroners decided that some men and women were insane or temporarily insane when they died, but others were not. Women who were respected members of their communities, particularly mothers, frequently received such verdicts of suicide while suffering from insanity. Women with bad reputations and fewer social connections, notably those who worked as prostitutes, did not.

As the first book—length study of St. Louis coroners’ inquests, this project examines valuable records for historians, which provide a glimpse into the daily life of ordinary men and women. These inquests are the remnants of the daily work of St. Louis coroners. Each day, they responded to various calls to investigate sudden or suspicious deaths. They interviewed witnesses, examined the body and its surroundings, and pieced together other clues, such as potential weapons near the body, letters, or suicide notes, to determine how and why a person came to a sudden death. Coroners’ inquests create challenges for historians because they are sporadic—containing records of only a few years or perhaps decades at a time for a given city. Some of the records contain only demographic data, such as name, age, and place of birth, and the verdict, with no witness testimony. But other inquests are pages long with rich material—statements from family members, neighbors, coworkers, and, sometimes, police officers or treating physicians. They explain the routines of these men and women, their habits, their work patterns, and relationships, all of which were disrupted by an early and, often, unexpected death. Coroners’ inquests also reveal the gritty details of life in an urban industrial center—the despair that some of the residents of St. Louis felt, the propensity that others had for violence, as well as the dangers of home and work.

Coroners’ verdicts offer insight into the belief systems and practices of coroners as well as those of the witnesses they interviewed. Witnesses told coroners that men and women were “respectable” or “rough,” whether they drank alcohol frequently, and whether they had threatened to die by suicide or to kill someone else. Members of a community contributed a great deal to coroners’ investigations and verdicts. Testimony from a friend or relative could inform a verdict of “suicide while suffering from mental aberration,” provide evidence of domestic violence as a contributing factor for a suicide or homicide, or that a death was an accident, with no evidence of suicide or criminal negligence. In addition to witness testimony, the coroner’s values and beliefs shaped verdicts. For instance, some coroners, such as John Frank, sought to find evidence to aid in the prosecution of physicians who performed criminal abortions more fervently than did other coroners. Other coroners, notably Hugo Auler, rendered more verdicts of suicide while suffering from insanity than did their counterparts.

Coroners had to distinguish between various causes of death for accuracy and public records, including city statistics about natural and violent deaths. These records also had meanings for society, revealing whether violent crime increased, for instance, or if an epidemic or extreme temperatures threatened the health of the city’s residents. A verdict also held meaning for families of the deceased. Coroners used a variety of verdicts both in their inquest records and in reports to the newly—formed Health Department, often noting a specific ailment, weapon, or person who caused the death. Coroners often framed verdicts in violent deaths with its type, such as “accident,” “homicide,” or “suicide,” but not always. They seldom noted when a death came from natural causes, but simply noted the illness—“pneumonia” or “congestion of the heart”—for instance. The evidence did not always clearly distinguish between the causes of death—a deadly fall could be an accident, suicide, or homicide, for instance, depending on the circumstances. Likewise, alcohol consumption could lead to a natural death from alcoholism or it could have been a contributor to a suicide, homicide, or accident. These verdicts had—and have—social meaning. A death from suicide or alcoholism could be stigmatized, while a death from abortion, accident, or homicide could lead to a criminal investigation and charges.

Because over twenty thousand inquests exist for the city of St. Louis between 1845 and 1900, this study focuses on a narrow time frame of ten years: 1875 to 1885, a period that features many inquests with ample witness testimony. The city of St. Louis operated under a new charter in 1876 and reorganized the government over the following year, including the election of a new Coroner. The new charter also mandated the formation of the Health Department and the city began to compile mortality statistics from death certificates, the Morgue, and the Office of the Coroner. The time frame also provides the opportunity to study families in greater depth by using the federal census, which is largely nonexistent for 1890.

Even for a ten—year period, thousands of inquests exist, so the cases for this study were chosen by using a combination of random and selected sampling. The initial sample came from viewing every case for every fourth month of each year and changing that set of months each year to ensure that all months were covered. The sample only included records for men and women between the ages of twenty and fifty, in order to better study violent deaths, which are more likely to occur for that age range. The first sample yielded 868 coroner’s inquests. Final selections to examine for this study were based on themes: prostitution, family violence, abortion, murder—suicides, verdicts of insanity, and investigations that required a coroner’s jury to render the verdict. The final sample included 120 cases. An approximately equal number of cases involving men and women as well as a range of ages, dates, and races and ethnicities were selected for each chapter. Some of these verdicts allowed for a study of family violence, while others, such as jury inquests, gave information about suspected homicides and typically featured several pages of witness testimony. Accidental and natural deaths provided a contrast to suspected suicides or homicides, as they seldom led to verdicts that would have a social stigma or lead to criminal charges. However, research into these types of deaths soon revealed that they were not necessarily easy inquests to conduct, as coroners looked for criminal negligence, possible homicides, or suicides.

While coroners ultimately determined how and why a person died, their verdicts were informed by their interviews with witnesses and were subsequently reported on by the press. Witnesses in the inquest and newspaper accounts of the death investigation and any subsequent criminal trials are also crucial to understanding how these deaths were investigated and interpreted. As with other American cities in the late nineteenth century, St. Louis employed white, educated men who conducted death investigations to determine how and why someone came to an untimely or suspicious death. St. Louis coroners had a distinctive qualification, however, as licensed, practicing physicians—qualifications that surpassed the state requirements in Missouri and many other states. In addition to their professional training and guidelines from the Missouri statutes, these men were also informed by their assumptions about race, class, and gender. The social location of the coroner was not the only factor in their verdicts, however. Coroners gathered significant information from a variety of people. The witnesses whom the coroners interviewed were similar to the deceased—often poor—to—working class, immigrants, prostitutes, people with addictions, and others who were excluded from respectable parts of St. Louis society. African Americans, women, and immigrants who were not yet citizens could not serve as coroners, but their testimony contributed to a coroner’s decision—that a loved one or neighbor died from a suicide, homicide, accident, or natural death. These witness statements offer a rare glimpse into the lives of people who often did not leave behind written records.

Coroners especially valued the testimony of family members and, at times, a tension existed between the evidence in an inquest and the interests of the family. Even when family members were not present at the time of death, such as workplace accidents, coroners often interviewed relatives first or put their testimony ahead of others in their records. When coroners rendered verdicts of alcoholism or suicide while experiencing insanity, it was not necessarily because of their medical training, but because of the testimony of the loved ones of the deceased. Conversely, when men or women did not have family members or close friends to testify on their behalf, coroners were less likely to render sympathetic verdicts to soften the stigma of certain kinds of deaths, particularly suicides. Without family members to interview, coroners were also more likely to conduct shorter investigations—unless another party may have been legally responsible, such as potential homicides. Coroners did not always listen to relatives, however, especially when criminal charges, burial rites, or public scrutiny were unlikely consequences attached to the verdict, such as with natural deaths. A coroner may ignore a wife’s statement about stomach pains, for example, and determine that another illness caused her husband’s death. Despite those anomalies, coroners relied heavily on witness testimony, particularly from relatives, to reconstruct the events that led to a sudden death. In the late nineteenth century, coroners had little else to rely on, as toxicology tests were rudimentary and autopsies rare.

Coroners’ verdicts have explanatory power and their accuracy is important. Variations among the verdicts because of witness testimony or the coroner’s own preferences impacted the data historically and in the present day. Determining that someone died from a criminal abortion, for instance, instead of an accident, could lead to sensational press accounts of the death as well as criminal charges for the abortion provider—often a physician or midwife. Coroners’ verdicts impacted public perceptions of a death and, in cases of homicide, abortion, or accidents caused by negligence, the criminal justice system. Coroners tended to conduct lengthier investigations into the deaths of men and women who were respected members of their communities, who had family members who testified about the causes of a loved one’s death, deaths that could possibly lead to criminal charges, and deaths that occurred in public. Coroners also often, but not always, conducted more thorough inquests into the deaths of men and women whom they understood to be good wives, husbands, mothers, and fathers.

[end of excerpt]

Table of Contents

CONTENTS

Acknowledgments

Introduction: The Office of the Coroner in Late—Nineteenth—Century St. Louis
1. Not as Simple as Disease: Coroners’ Verdicts of Natural Deaths
2. “She was a Hard Drinker:” Gender, Deaths from Alcoholism, and Insanity
3. “Whilst Laboring Under Mental Derangement:” Coroners’ Verdicts of Insanity, Suicide, and the Family
4. “With the Intention of Producing an Abortion:” Coroners as Enforcers of Abortion Laws in St. Louis, Missouri
5. “I am Afraid that You Will Beat me to Death:” Coroners’ Inquests into Domestic Homicides
6. “No one was Blamed:” Coroners’ Inquests into Deadly Workplace Accidents
Conclusion: The Importance of Death Investigations in the Past and Present

Bibliography
Index

Editorial Reviews

This study of the history of coroners’ inquests in St. Louis during the late nineteenth century makes a valuable contribution to death studies. Providing a look into the lives of ordinary people and the factors that shaped investigations, Sudden Deaths illuminates the social meanings and implications of class and urban economy in the Gilded Age.”—
Keona K. Ervin, author of Gateway to Equality: Black Women and the Struggle for Economic Justice in St. Louis

“The ordinary men and women who people this book meet tragic ends—driven to death by grief at the loss of a child, killed at work in a boiler explosion, fatally beaten by a spouse, or dying from a botched abortion. Lirley brings a strong sense of justice to a fascinating source base and reveals the drama of social history.”—Alison Clark Efford, author of German Immigrants, Race, and Citizenship, in the Civil War Era

“In this fascinating, new exploration of coroners’ inquests and violent deaths in Gilded Age St. Louis, Lirley uncovers how one’s social standing—whether they were ‘respectable’ or ‘rough,’—shaped interpretations of their death. Connecting race, class, and gender with questions of insanity, homicide, suicide, abortion, alcoholism, and medicine in death testimonies and verdicts, Lirley extends a history more relevant today than ever.”—Cassandra L. Yacovazzi, author of Escaped Nuns: True Womanhood and the Campaign against Convents in Antebellum America 

“This meticulously researched book uses nineteenth—century investigations of suspicious deaths as a window into the private circumstances and public meanings of the lives and deaths of St. Louisians. Lirley’s exhaustive research into coroner’s records is a treasure trove of information about the daily worlds of women, African Americans, and immigrants navigating work, domestic conflict, pregnancy, alcoholism, and depression.”—Catherine E. Rymph, author of Republican Women: Feminism and Conservatism from Suffrage through the Rise of the New Right 

“Lirley provides a provocative look at the Gilded Age from a unique perspective that explores not just race and gender but also the seamy undersides of both cities in the period and the ways deaths were reported and treated.”—Jeffrey Smith, author of The Rural Cemetery Movement: Places of Paradox in Nineteenth—Century America

“In the early Gilded Age, elected St. Louis coroners investigated unexpected death, such as those resulting from domestic violence, suicide, abortion, or traumatic accident. These coroners brought not only science and law to their work but social judgment. Similar deaths were often judged differently. They could spare a respected family embarrassment on the one hand, or effectively condemn those judged guilty of moral turpitude—prostitutes, the dissolute, the perpetrators of domestic violence, or the sin of poverty, on the other. Lirley’s revealing study is the first to make systematic use of these now readily accessible records, reconstructing both the harshness and occasional charity that still resonate in our world of opioid and COVID—19 deaths.”—Kenneth H. Winn, editor of Missouri Law and the American Conscience: Historical Rights and Wrongs

“In this captivating study of death, we learn a great deal about life, especially the lives of the marginalized in Gilded Age urban America. Lirley mines overlooked coroners’ inquests in turn—of—the—century St. Louis, rich sources for historians of violence, medicine, family and labor, for the social meaning of death. In her gleaning of witness testimony, Lirley unearths obscured or hidden topics, affording historians a rare glimpse into the daily lives, and deaths, of poor and working—class Americans, including immigrants, prostitutes, the addicted and African Americans. This is a must—read book for anyone interested in the study of death.”—Diane Miller Sommerville, author of Aberration of Mind: Suicide and Suffering in the Civil War-Era South 

“While the book presents academic research about many grisly deaths, it is also an easy read. It offers a fascinating social history that reveals the daily lives of women, African Americans, and immigrants experiencing domestic abuse, pregnancy, alcoholism, depression, and hazardous working environments.”—Andrea Merritt and Sydney Jones, Missouri Life Magazine

"Sudden Deaths in St. Louis is a valuable contribution to the history of medicine and death investigation. It would appeal to historians interested in social, medical, and urban history."—Shelby Zimmerman, Trinity College Dublin

"In this well—researched volume, historian Sarah E. Lirley meticulously unearths the inner workings of the late nineteenth—century St. Louis coroner’s office.... Lirley has produced a memorable and well—researched social history that not only illuminates the history of coroners’ offices and death investigations but also powerfully illuminates life and death in the Gilded Age."—Jonathan S. Jones, James Madison University

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