I just heard a bit about this in a commentary on the Lizzie Borden case, which I don't think involved an elected medical examiner, I can't remember that, but they mentioned some places had elected medical exaiminers, that back in the day it could be more of a publicly influential position. Cause of death was way, way more subjective than it is today, and local fortunes and family legacies could be riding on the determination, which was the case in the Lizzie Borden matter.