August 27, 2025
By Sarah E. Lirley
Death is a fascinating historical topic and coroner’s inquests into unexpected or suspicious deaths are even more so. I examined 120 such inquests for my book, Sudden Deaths in St. Louis: Coroner Bias in the Gilded Age. The book is divided into six chapters, with each one focusing on a different cause of death, as determined by investigating coroners: natural causes, alcoholism, suicide, abortion, domestic homicides, and workplace accidents. 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, as well as the reputation and social connections of the deceased. Each chapter highlights two coroners’ inquests found in my research—one typical and one atypical case.
One of the most compelling cases that I came across was the 1879 suicide of Estelle Johnson, an atypical case because of her prominence. Johnson was one of a few people who received a verdict of suicide while suffering from insanity because she was a grieving mother and a respected member of her community—the wife of the former Lieutenant Governor of Missouri. Men and women with bad reputations and fewer social connections were less likely to receive a verdict of suicide while experiencing a mental illness. The inquest into Estelle Johnson’s death is explained in Chapter Three of the book. Here is part of her story:
Charles P. Johnson rushed home from his law office at 4:00 pm on September 2, 1879, to attend to his wife, Estelle, whom he had just learned was very ill. She was being treated by Drs. Smith and Ware when he arrived. The physicians told Charles the reason for his wife’s sickness: an intentional overdose of arsenic. Panicked, Charles asked, “Great God! Ese? Why did you do this?” and she replied, “Oh pet, I could not help it.” His panic subsided when Estelle seemed to get better. Charles probably hoped that she would recover and finally overcome the melancholy from which she had suffered for months, since the death of their two-week-old daughter, who had been born prematurely. Charles returned to his office, confident of his wife’s recovery, and came home that evening. Unfortunately, his hopes were soon dashed.
Estelle grew worse and passed away at 10:00 that night, leaving behind her husband and four children. Charles attributed his wife’s suicide to a “mania” due to the loss of their two-week-old child. He claimed that her mental illness became especially severe because of her devotion to her family, adding that “there was no nobler, and truer little wife, or a more kinder and affectionate mother.”
The next day, Coroner Hugo Auler investigated her death. Auler learned from family members that she had attempted suicide before and had become addicted to opiates. Dr. Smith had cared for Johnson for some time, but her condition had not improved. Her relatives told Coroner Auler that Estelle Johnson was a religious woman and one who loved her family very much, but she was overcome by an “impulse” to die by suicide. Auler determined that Johnson died “from the effect of Poisoning by arsenic, administered by her own hands, result of mental aberration, caused by grief, at the death of her child.”
There was no medical basis for Auler’s verdict. Drs. Ware and Smith discussed only Johnson’s symptoms, evidence of arsenic poisoning, their efforts to treat her, and her death in their testimony before the coroner. They mentioned nothing about insanity. Johnson’s family, however, told the coroner about a history of despondency since her last child died. Coroner Auler took her family’s testimony seriously.
As Chapter Three argues, Johnson’s character, family testimony, and Coroner Auler’s empathy all contributed to her verdict. Adding the qualifier of “insanity,” or “temporary insanity” softened the stigma of a suicide verdict. The chapter explains this practice in greater detail and also explains other inquests, press coverage of suicides, and how Dr. Auler’s background shaped his approach to these inquests. Coroners did not render verdicts of insanity with consistency; they each had their own set of criteria. One common factor, however, was the statements of family members that their loved ones had suffered from some kind of “mental aberration.” But even testimony from relatives was not enough to overcome perceived shortcomings in one’s character. In Coroner Auler’s view, Estelle Johnson was a grieving mother who deserved sympathy.
Sarah E. Lirley’s new book, Sudden Deaths in St. Louis: Coroner Bias in the Gilded Age is available from Southern Illinois University Press.
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).