The Cadaver King and the Country Dentist

by Radley Balko

  The first standardized system of investigating suspicious deaths was established in ancient China, predating Antistius by several centuries and other European efforts by nearly a millennium. In the 1970s, archeologists working in China’s Hubei Province discovered a collection of engraved bamboo strips titled “Models for Sealing and Physical Examinations” dating back to the Qin Dynasty of the third century BCE. The texts speak not only to postmortem analysis of corpses but also to the investigation of potential criminal conduct, with detailed instructions for finding and preserving evidence, interrogating suspects, ascertaining the identity of perpetrators, and distinguishing suicides from staged hangings. In 995 CE, the Song Dynasty issued a decree establishing the first known inquest system for suspicious deaths. Under it, local authorities were required to alert government investigators after discovering or learning of an unexpected death. The decree mandated something akin to the modern autopsy report, requiring local officials to summarize findings of their investigations, including sketches of the anterior and posterior of the body with annotations to indicate the corpse’s condition, the location of wounds, and so forth. The reports were considered public documents. If an investigation revealed that a death was caused by an illegal act, the decree compelled officials in a neighboring jurisdiction to perform a separate and independent investigation.

  In 1248, a Chinese criminal investigator named Sung Tz’u authored Washing Away of Wrongs, likely the first forensics manual ever published. One of the book’s lessons recounts the story of a criminal investigator called to a village to investigate the murder of a local farmer who had been slashed to death. The investigator gathered all of the villagers in a central location and then requested that they bring their sickles forward and place them on the ground. When flies gathered on one of the sickles, presumably drawn to invisible traces of blood, the sickle’s owner confessed.

  Though not as sophisticated or as organized as the Chinese system, sixth-century Europe saw similar developments in the Justinian Code, which required physicians to assist courts with advice and interpretation of evidence. By the late 1500s, forensic medical texts were spreading throughout Western Europe, gradually becoming a feature of most criminal investigations. By the mid-1600s, medical specialists routinely performed some type of postmortem examination and testified in criminal courts across the continent.

  The United States inherited its death investigation system (as well as much of its common law) from the English. It was the English who created the position of coroner, a widely overlooked and misunderstood public office that dates back to the Norman Conquest. While there were similarities between the British coroner system and the death investigation systems that had been present for centuries in China and in medieval Europe, those systems—particularly that of the Chinese—were designed from the start for the primary purposes of determining the cause of suspicious deaths and the administration of justice. The English story is quite a bit more convoluted.

  The coroner system in Britain began more as a means to an end, and the end was collecting tax proceeds for the king. Most historians credit the creation of the coroner to Hubert Walter, an advisor to King Richard I. Five years into Richard’s reign, England found itself in dire financial straits. The crown’s claim that the Third Crusade was mostly successful may have been true, but the fight had been funded with unpopular new taxes. The kingdom’s financial woes only worsened when, on his way back from the Middle East, Richard I was kidnapped and held for ransom. Hubert Walter paid what the captors demanded, but the steep cost plunged England further into crushing debt.

  Desperate to refill the country’s coffers, Walter issued a new law in 1194 calling for each county in England to elect three knights and one clerk “to keep the pleas of the crown”—basically, to oversee the crown’s exclusive business. These officials became known as “crowners,” or agents of the crown. The term eventually morphed into “coroners,” after the Latin custos placitorum coronas, or “keeper of the crown’s pleas.”

  While coroners didn’t have law enforcement powers, they were the only local officials who had the authority to arrest the sheriffs. The latter, charged with keeping the laws in their respective jurisdictions, had become notoriously corrupt, and the king’s aides found their thieving and pilfering particularly irksome now that the country was in debt.

  The “coroner” concept—and mission—was vague, and probably intentionally so. Walter believed that keeping the coroners’ duties loosely defined provided political flexibility. It allowed him to alter the position as needs arose, whether by diminishing the power and influence of the sheriffs, or by improvising ways in which the coroner could collect more taxes and fees.

  Initially, the coroner’s most important responsibility was to keep records in each county for the Royal Courts of Law. The king levied taxes and fines based on these records. It wasn’t long before the tax-happy crown saw revenue potential in life’s only certainty: death. Today the terms “coroner” and “death” are inseparable. But coroners came to oversee death investigations really as an afterthought—the by-product of a twelfth-century king desperate to raise some money.

  As a result, the early English coroner’s main task was not to determine the cause of death, or even identify the parties responsible for untimely deaths. Most English communities at the time were small and close-knit enough that in the event of a murder (which was rare), the identity of the killer was typically known to everyone. The primary purpose of the coroners’ death investigations was to levy the appropriate taxes, fines, and surcharges associated with passing away. Walter had also imposed a “death duty,” a fee imposed on the family of the deceased, and levied taxes on the deceased’s chattel and other property. Not surprisingly, all of this made coroners rather unpopular.

  Eventually the crown found new ways to tax death—ways that required someone to figure out how the death had actually occurred. A death resulting from homicide or negligence, for example, allowed the crown to seize the land and holdings of the responsible party through forfeiture. A crime like murder might also invoke the doctrine of “corruption of blood,” in which both the perpetrators’ property and their inheritance rights were forfeited to the crown. Under the “murdrum” doctrine, a village could be fined for any murder in which it couldn’t be proved that the victim was Saxon. That law was meant to protect the Norman aristocracy from reprisal killings by the conquered Saxons. The rules for death investigations eventually became so onerous that some English citizens began ignoring dead bodies or hiding them. In some instances, corpses were covertly deposited in nearby villages as a way to avoid the increasingly expensive hassle.

  Given that the office of coroner was never intended to focus on medical issues, early English coroners rarely if ever had any medical training. In fact, the original requirements to hold office were only that one be a knight and that one be affluent. The wealth requirement was meant to immunize against corruption and bribery—coroners were unpaid. (Predictably, this had the opposite effect.) English coroners also had other odd jobs, such as ensuring that the accused showed up for criminal trials at the county courts; taking confessions from criminals who had sought sanctuary in churches; determining the owners of “treasure troves” (money found buried in the ground); investigating shipwrecks and fires; and confiscating any whale or sturgeon caught by fishermen, or that happened to wash ashore (both were considered too valuable for commoners, and thus the property of the crown).

  By the late Middle Ages, practices like murdrum fines and death duties had fallen out of favor or been eliminated entirely. Other responsibilities, like tax and fine collections, were transferred to other public offices. What remained—death investigation—became by default the coroners’ primary responsibility. Gradually, the position came to be occupied by people with skills better suited for the job, typically physicians and attorneys.

  The Industrial Revolution and urbanization hastened this evolution, as the booming population in London brought a surge
in violent crime, disease, and factory deaths. Increased attention to public safety prompted coroners to more actively investigate accidental and negligent deaths, as well as homicides. The Coroners Act of 1887 repealed a number of the more antiquated policies and rewrote the powers and responsibilities of coroners to better position them for that role. Today, a British coroner’s primary responsibility is to oversee death investigations, although they’re still asked occasionally to administrate the proceeds from “treasure troves.”

  This was the system that the United States inherited. Like their British counterparts, early American coroners attended to death investigations but were also assigned a mixed bag of other responsibilities. (Until the 1980s, for example, Mississippi coroners were responsible for rounding up any stray livestock in the county.) As in Britain, the coroner position was important, though often taken for granted and underappreciated. Most coroners were appointed to the position; others were elected. In some states the position was specifically written into state constitutions, which set forth general duties, qualifications to serve, and certain enumerated powers. Many states also preserved the English tradition of designating the coroner as the only local official with the power to arrest the sheriff—a tradition that persists today.

  Because colonial America was mostly agrarian with few large cities, the primary qualifications for coroner tended to be less about training and education and more about practical concerns—such as owning a wagon that could haul bodies. As in early England, colonial American towns were close-knit and fairly homogenous. On the whole, homicides were rare.

  When coroners were presented with an unexpected death, they would empanel a coroner’s jury—a group of men assembled to investigate. Historical records suggest that early American coroners and their jurors were unlikely to possess medical training or other expertise, and instead tended to rely on common sense and general observation to reach their conclusions.

  During the Jacksonian era of populist government in the early 1800s, many public offices that had traditionally been gained by appointment became, instead, elected positions. In most of the country, that included the coroner. “Jacksonian Democrats celebrated the intelligence and integrity of the common man while belittling the attainments of the social and professional elite,” writes historian Julie Johnson-McGrath. “Thus, as the western territories were settled and the number of coroners grew, there was no accompanying demand that they possess medical or legal credentials. Political, not professional skills were what was demanded of potential coroners.”

  As a result, the coroner’s office did not evolve into a public service position for doctors and other medical professionals, but instead into an accessible entree into political life. Death investigations suffered as a result. Though nearly all coroners of the era had the authority to convene an inquest into a suspicious death, few had the power or the will to order an actual autopsy. Even if they had wanted to, there weren’t many doctors around to give their medical opinion on a cause of death. Some American medical scholars agitated for a system more in line with Europe’s, but the country was still sparsely populated and remained largely devoid of the type of specialists required to populate any field resembling modern forensic pathology. Worse, not only was there a shortage of qualified physicians to provide expertise to inquest jurors—even within the limits of the knowledge available at the time—but courts generally deferred to those physicians who were consulted, regardless of their qualifications. And even among the handful of qualified physicians, a coroner with no medical training could frequently trump a doctor’s conclusions.

  Physicians began to resent coroners, and the medical profession in general began to lose interest in lending its expertise to the criminal justice system. Thus began the adversarial relationship between science and law. The tension between the two would undermine the evolution of forensic pathology for the next two centuries.

  Sensing that the problem was just as much about supply as demand, some in the medical community, such as the American Medical Association, began to advocate for making jurisprudential medicine a more prominent part of the medical school curriculum. The group even advocated abolishing the coroner’s office. But though it continued to advocate doing away with coroners throughout the latter half of the nineteenth century, the AMA lacked the political leverage to persuade state legislatures, and its reform efforts were stymied by the era’s growing distrust of elites.

  The medical community offered expertise, practical reforms, and a concern for public health. The coroners countered with protectionism, cronyism, and raw political power. The coroners won out. It was during this period that the institutional structure for the coroner system was built, and along with it came the rise of the factions and interest groups that benefited from its continued existence. It would prove extremely difficult to tear down. The animus between the coroners and the medical community, and the inability of the latter to navigate the politics of the former, explains in part why until relatively recently the scientific community has generally steered clear of the criminal justice system. The resulting vacuum allowed law enforcement interests, politics, and rank charlatanism to fill the void.

  By the early 1900s, American public sentiment began to warm to elites. This period saw the rise of progressivism, a political ideology that tended to revere professionals, embrace the pursuit of knowledge, and push for improvements in public health and safety. Breakthroughs in fields like bacteriology, virology, and general germ theory brought the medical profession new prestige. Previously, doctors had merely helped manage illness and death. The country now looked to them to prevent those things.

  As progressives positioned themselves as the enemies of corruption and machine-run politics, coroners emerged as a ripe target. The office had become extremely powerful, especially in large cities. In some cities the coroner’s office had more investigators than there were detectives in the police department. In other places, the coroner had prosecutorial powers on par with a district attorney.

  Coroner’s deputies, who were usually in charge of claiming bodies and transporting them to the morgue, routinely collected bribes from undertakers in exchange for recommending embalming and funeral services to the families of the dead. They were also known to loot personal belongings from corpses. The fees earned by coroners and their juries for inquests provided additional opportunity for graft and political patronage. Coroners had great discretion over their juries’ conclusions. They could mediate, negotiate, or outright auction off a cause of death. Ample opportunity existed to do just that. The family or associates of a prominent businessman might bribe a coroner to turn a suicide into an accident. The wealthy family of a woman who died of complications from an abortion might pay a coroner to rule that the death was from natural causes. Insurance companies typically didn’t pay benefits in cases of suicide, but they might pay double or more for an accidental death. As the country industrialized, factory deaths became an increasingly urgent health concern. Any insurance company able to influence a coroner’s jury to find contributory negligence on the part of the deceased could save a fortune in claims.

  While the Jacksonian-era push to elect coroners was intended as a check against corruption, party machines rendered the change ineffective. The coroner morphed into a patronage position handed out by party bosses. Some coroners ran on promises to slash budgets by requesting fewer autopsies, a policy that in an era of rising crime, rapid industrialization, and disease from overcrowding could be disastrous for public health.

  Most states required little in the way of qualifications to run for coroner. In many places, a candidate needed only to be of voting age and pass some arbitrary test of moral character. The law in North Carolina was typical: coroner candidates needed only to have renounced atheism and to have never participated in a duel.

  The progressives sought to end these problems by moving away from coroners toward a medical examiner system. But the field of forensic pathology (the field in which medical examiners pract
ice) continued to suffer from a familiar problem: there just weren’t very many medical examiners around. Most bright, ambitious young physicians went to medical school to save lives, not to work with the dead. As Julie Johnson-McGrath writes, “The popular conception of the coroner’s physician was a broken-down, alcoholic wreck unfit to treat the living, or a sociopathic personality who preferred the company of the dead. It was hardly the company a talented young physician would care to join.”

  In 1911, an Illinois jury convicted Thomas Jennings of murder committed in the course of a burglary. The case would have been unexceptional save for a piece of evidence that had never before been used in an American courtroom, and that was central to the prosecution’s case: a fingerprint. According to the prosecution, the print was left on a freshly painted railing. The railing also happened to be near the perpetrator’s point of entry. Police analysts determined that the print was a match to Thomas Jennings. It was the only solid evidence against him. The victim’s traumatized wife had been unable to pick Jennings out of a lineup, and though Jennings—an experienced burglar who had done time at the state prison in Joliet—had been subjected to a physically brutal interrogation, he never confessed.

  The jury convicted. When Jennings’s lawyers challenged the admission of the fingerprint evidence on appeal, the Illinois appellate court affirmed the conviction, finding that “the court and jury were properly aided by witnesses of peculiar and specialized experience on this subject.” Jennings was hanged.

  By the time of Jennings’s trial, Europe had been using fingerprint evidence in its courts for several decades. In fact, it was Scotland Yard detectives who introduced it to the American populace at the 1904 World’s Fair in St. Louis. That particular World’s Fair was in many ways the ideal venue for the birth of American forensics. The fair’s theme was all about American achievement in science and technology. It celebrated the young country’s rapid industrialization and the cities’ sprint toward electrification.