Tag Archives: dissection

Post-mortems in the asylum and issues of consent

Our last post explored why post-mortems were considered essential to the scientific study of mental illness in the 19th century, with the procedure establishing cause of death and gathering pathological information that could be correlated with clinical notes taken during life. How was consent for post-mortems obtained, though, and how much input did patients’ friends and families have on the practice?

Seeking consent

That the bodies of asylum patients were considered important repositories of knowledge can be seen in the efforts made by asylum doctors to secure them for post-mortem examination. Eric Engstrom, investigating German psychiatric clinics, describes how ‘valuable neuropathological specimens’ were offered free beds in order to obtain access to their bodies after death. In Britain, there were appeals during the 1870s for post-mortems to be made a universal, automatic practice within medical institutions. Despite the support of prominent alienist Sir James Crichton-Browne and others, efforts to institute ‘carte blanche post-mortems’ were rejected in 1877, though this did not mean that all asylums followed the same protocol with regard to the procedure. Jonathan Andrews summarises: ‘At some asylums post-mortems had become de rigueur, formal consent not even being sought. At a minority, prior consent was procured from patients while living. Whereas a few sought written consent using purpose-specific pro-forma, others relied merely on verbal consent’.

L0000838 Section of the brain, 19th century.

At the West Riding Asylum in Yorkshire, the intent to perform a post-mortem was made clear on the notice of admission sent to relatives: ‘In case of death the usual post-mortem examination will be made in order to certify correctly the cause of death. Relatives in any case objecting to this course are requested to communicate immediately upon receipt of this notice, personally, with the Medical Superintendent.’ It is impossible to know how many families responded – or indeed were able to respond, depending on literacy levels – to this specific advice. Towards the end of the 19th century it is clear that some relatives were voicing their objection to post-mortem. Casebooks kept during the patient’s life might be annotated ‘Post mortem objected to’, or alternatively ‘No objection to P.M.’

Sample of a post-mortem book, 1899. © WYAS, Wakefield.

Sample of a post-mortem book, 1899. © WYAS, C85/1132.

Determining the specifics of post-mortem

Post-mortem records show that some families had very specific ideas about where the boundaries lay, and Andrews notes that this might be particularly evident if families belonged to a religious denomination that emphasised resurrection. Even amongst people without such beliefs, though, the idea of a post-mortem was – and is – a difficult one to deal with. In Speaking for the Dead, the authors relate the case of a mother whose son was killed in a road accident. Two years after his cremation, she and her family discovered that her son’s brain had been removed, and that his body had thus not been intact at his cremation. “It was my son’s heart and brain that made him what he was,” she said, and this is a feeling that crosses many cultures – of the brain as intimately bound up with the self.

There is a sense of this in several 19th-century records too. Often the ‘[h]ead [was] not permitted to be examined’, though there were some exceptions in which the head only was specified, possibly if the potential value of the exam to the wider study of mental illness had been emphasised by the doctor. Usually, the thorax was the part viewed by the family as an acceptable area of investigation, with records noting ‘Chest only examined’, or ‘Thorax only permitted to be examined’.

From J.M. Beattie, Post-Mortem Methods, 1915. © Wellcome Library, London.

From J.M. Beattie, Post-Mortem Methods, 1915.
© Wellcome Library, London.

There were also moves towards making death a less harrowing experience for patients’ families, with separate chapels set up apart from the mortuary. Reporting on the arrangements at Claybury Asylum, the British Medical Journal reported:

‘Our representative was much struck by the care taken to save the feelings of the friends of the dead. There is a cheerfully-furnished waiting-room for their special use; when they wish to take their last look at the departed the coffin is wheeled into the central hall where there is no trace of anything unpleasantly suggestive.’

Whilst asylum staff were keen to examine the bodies of deceased patients, then, there was increasing awareness that friends and families had a place in decisions about post-mortem practices, even if this was a time at which consent procedures were still being elaborated.

Further reading

J. Andrews (ed.), History of Psychiatry 23 (Mar. 2012) – Special issue: ‘Lunacy’s last rites: dying insane in Britain, c.1629-1939′.

S.  Ferber and S. Wilde (eds.), The Body Divided: Human Beings and Human ‘Material’ in Modern Medical History (Farnham: Ashgate, 2011).

E.T. Hurren, Dying for Victorian Medicine: English Anatomy and its Trade in the Dead Poor (Basingstoke: Palgrave Macmillan, 2011).

R. Richardson, Death, Dissection and the Destitute (London: Phoenix, 2001).

M. Sappol, A Traffic of Dead Bodies: Anatomy and Embodied Social Identity in Nineteenth-Century America (Princeton: Princeton University Press, 2002).

Post-mortems in the asylum: What were they for?

DSCF1077Last month, the Idaho State Journal reported that 120 headstones had been placed on the graves of former patients at State Hospital South (previously Idaho Insane Asylum). The new markers were unveiled as just one stage in an ongoing project of placing headstones on over 1,000 unmarked graves in the area. The unmarked or numbered graves of the asylum cemetery provoke strong feelings for present-day observers, suggesting large numbers of people who were forgotten by relatives, as well as raising questions about past psychiatric treatment. Reports on the unveiling of the latest headstones noted that some patients underwent lobotomies and other procedures. The Hospital’s current administrator said that, in the treatments they had undergone, these patients could be considered ‘pioneers’ in the treatment of mental illness whose legacy can still be seen today. Commemorating the dead in a cemetery leads us inescapably to the body of the asylum patient, something that is present throughout my own research and that can’t be overlooked when considering the history of psychiatry.

In the 19th century, the physical body was at the heart of much psychiatric research, but it is the body at post-mortem that this and a subsequent post will focus upon. In the search for the origins of mental illness, the post-mortem was crucial for asylum doctors and was a practice increasingly encouraged by the Commissioners in Lunacy in order that the ‘scientific spirit’ of asylum research be kept up. At the West Riding Asylum for instance, an 1885 Commissioners’ report noted that ‘[t]he number of post-mortem examinations, 193, [was] very satisfactory’.

What were the purposes of the post-mortem?

Why were the Commissioners so interested in the amount of post-mortems being performed? Firstly, as in any other medical arena, the post-mortem was crucial in identifying the cause of death. The West Riding’s Regulations and Orders of the Committee of Visitors stated that ‘A post-mortem examination [would] be made of the body of every Patient dying in the Asylum, and a searching inquiry … instituted as to the cause of any bruise or injury found upon a body’. As well as establishing the immediate cause of death, then, the asylum post-mortem acted as a check on asylum care. In examining the state of the body at death – post-mortem books might remind the doctor to note things such as bedsores, fractures, or if the body was emaciated – the procedure mirrored the admission exam in which the patient was bathed and checked for physical injuries. Sometimes the post-mortem revealed injuries that had been overlooked during life (such as a broken bone), and in this way could be conceived of as a deterrent to any attendants who were tempted to use violence towards patients.

Brain dissection, seen from above. © Wellcome Library, London.

Brain dissection, seen from above. © Wellcome Library, London.

Secondly, the post-mortem was a means of gathering evidence about the pathology of mental illness. Unusual appearances within the skull itself – adhesions of the membranes to the surface of the brain, blood clots, or wasting away of the brain substance – were recorded and tabulated in order to establish any patterns. Francis O. Simpson’s The Pathological Statistics of Insanity (1900) collected together a staggering amount of post-mortem data, organised by type of mental affliction so that the reader could chart the appearances found in the brains of melancholic, maniacal, or epileptic patients. Post-mortem record books might have an index added by recording doctors, where one could look up all instances of ‘adhesion’ or ‘haemorrhage’ in order to identify any similarities between the cases.

Thirdly, such data could be matched up with the clinical information kept on a patient during their lifetime. That post-mortem books often allowed the practitioner to note the ‘Form of mental disorder at admission’ and ‘Form of mental disorder at death’ suggests that mental illness wasn’t necessarily viewed as a static condition, but also – as Gayle Davies notes in ‘The Cruel Madness of Love’ – that the post-mortem could sometimes lead to a ‘re-diagnosis at death’. Conversely, the post-mortem often confirmed the suspicions of the doctor about the root of a patient’s problem, with a tumour or other anomaly found in the region of the brain that corresponded to a motor disorder exhibited during life.

Asylum museums were often smaller versions of those like the Royal Free Hospital's, above. © Wellcome Library, London.

Asylum museums were often smaller versions of those like the Royal Free Hospital’s, above. © Wellcome Library, London.

Lastly, this focus on the physical fabric of the insane body as a site of knowledge about mental illness led to many body parts being preserved for asylum museums. These on-site museums were used for teaching purposes as well as forming a permanent ‘catalogue’ of brain anomalies. Some specimens might be ‘put aside for hardening for general purposes’ – likely for students to examine or practice their dissection skills upon – or even sent to a researcher at another asylum for study (a brain from a patient at the West Riding Asylum who died in the early 1870s was sent to fellow alienist John Batty Tuke to examine). Towards the end of the century, bacteriological research also began to draw upon the fabric of the body, with  a researcher in 1895 ‘[inoculating] slices of sterilized potato … with blood from [a] spleen … [A] pure cultivation of typhoid bacilli resulted’. The post-mortem was, then, bound up with several other practices evolving at the time, and was a site where doctors honed their pathological skills as well as accounted for the basic facts of death.

Within all this, it often seems that the patients themselves are worryingly absent. What were the rules governing consent for post-mortems? Did families know what precisely a post-mortem entailed? Did they voice their objections to the asylum doctor? These are questions I’ll be turning to in our next post. In the meantime, for a fuller discussion of all of these issues you might like to take a look at a special issue of History of Psychiatry journal, ‘Lunacy’s last rites: dying insane in Britain, c.1629–1939’.