Tag Archives: neurology

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’.

The Ophthalmoscope: Viewing The Living Brain

Continuing the theme of medical technologies in the asylum, I’d like to turn to another, much more common instrument, but one whose role in psychiatric study is less well-known: the ophthalmoscope.

The ophthalmoscope in use, 1872. © Wellcome Images.

Created and described by Helmholtz in 1851, the ophthalmoscope was an instrument that allowed one to see into the back of the eye, revealing specific retinal conditions in diagnoses such as leukaemia, syphilis and diabetes. In particular it revealed the optic disc, the point at which the optic nerve reaches the eye from the brain, thus giving privileged access to the condition of the cerebral matter and the state of circulation in the brain. Short of opening up the skull, this was the only means to view any part of the brain in a living patient; and given that asylum doctors in the nineteenth century were committed to a somatic view of mental illness, and were looking for the physical (cerebral) causes of insanity, this was a useful tool. Yet a conservative medical profession in Britain was often resistant to new instruments replacing the experience and acumen of trained physicians, believing that such experimental, laboratory methods could never supplant the use of unaided  senses in the clinic. There were thus initially few British adherents, with Thomas Clifford Allbutt (1836-1925) complaining in 1871 that he could ‘count upon the fingers of one hand’ the number of physicians working with the ophthalmoscope in England.

Sir Thomas Clifford Allbutt. © National Portrait Gallery, London.

[There was a strong rumour, still perpetuated today, that Allbutt was the model for Dr. Lydgate in George Eliot’s Middlemarch (first published in serialised form between 1871 and 1872). This is probably wrong, though Eliot did visit Allbutt in September 1868, and wrote that he was a ‘good, clever, graceful man, enough to enable one to be cheerful under the horrible smoke of ugly Leeds’!]

Allbutt, the main proponent of ophthalmoscopy in nineteenth century Britain, was a physician and lecturer at the Leeds General Infirmary, and conducted some of his work at the nearby West Riding Lunatic Asylum (some patients under his care would occasionally make the same journey too). In his classic monograph On the Use of the Ophthalmoscope in Diseases of the Nervous System and of the Kidneys (1871), Allbutt included an appendix of two hundred and fourteen cases of insanity he had observed with an ophthalmoscope at the asylum. He found changes in the eye in a large proportion of those diagnosed with old or organic cases of brain disease. The usefulness of the ophthalmoscope in the asylum was clear to him, as he argued it would help remove ‘the metaphysical or transcendental habit of thought’ and bring a ‘more vigorous and more philosophical mode of investigation’ to disorders of the brain.

Images of optic neuritis taken from Allbutt’s 1871 book.

Allbutt’s work was continued at the asylum by Charles Aldridge, a young doctor who investigated blood supply in the brain using the ophthalmoscope, a tool which he said was ‘able to diagnose obscure cerebral affections through its instrumentality’. It had long been thought that blood flow, particularly an increased level leading to cerebral inflammation, was at the root of many instances of mental disease. As late as 1879, Bucknill and Tuke still argued that it ‘is most probable that inflammation is not the condition of insanity, but is the exciting cause of a secondary pathological state upon which the symptoms of insanity immediately depend’. The frequency with which inflammation, clots and congestion were found in post-mortem asylum cases was evidence of this.

Physiological experiments had shown that blood flow – and the nutrients, oxygen, and poisons it might contain – was crucial to normal cerebral functioning, and thus provided a route for doctors to describe and explain various mental conditions. In three papers in the 1870s, Aldridge presented his observations of cases of epilepsy, general paralysis and dementia using the ophthalmoscope. He concurred with Allbutt that general paralytics displayed atrophy of the optic disc, and further claimed that one could estimate how long the disease had existed by the relative amount of atrophy. Epilepsy, he found, was concurrent with a state of ‘passive hyperaemia’, whereby blood flow away from the brain was impeded, creating cerebral pressure. By contrast, dementia, whose sufferers were characterised by paleness of the optic disc, probably had its origin in a state of anaemia of the brain. The ophthalmoscope seemed to offer the possibility of diagnosis in all types of insanity.

However, whilst the ophthalmoscope did eventually become a popular instrument amongst general medical clinicians – and those dealing with disorders of the eye or nervous system in particular – it never really took hold in asylum practice. It could be used in the diagnosis of general paralysis, but this was a disease which could be more easily confirmed through other symptoms. And in other forms of insanity the ophthalmoscope was less reliable, as there was no constant causal relationship between lesions in the brain and observations of the eye. Instead, doctors would have to rely on other diagnostic criteria, and wait for the mortuary to make any specific claims about the state of the brain. The ophthalmoscope in the asylum is  illustrative of the way in which the potential uses and limits of new medical technologies are tested, and also of the way nineteenth-century asylum doctors followed a variety of leads in their attempts to link mental diseases with specific physical causes.

Further Reading

C. Aldridge, ‘The Opthalmoscope in Mental and Cerebral Diseases’, ‘Opthalmoscopic observations in general paralysis, after the administration of certain toxic agents’, ‘Ophthalmoscopic observations in acute dementia’, West Riding Lunatic Asylum Medical Reports, 1-4 (1871-1874).

T.C. Allbutt, On the Use of the Ophthalmoscope in Diseases of the Nervous System and of the Kidneys (London/New York: Macmillan & Co., 1871).

C. Lawrence, ‘Incommunicable Knowledge: Science, Technology and the Clinical Art in Britain 1850-1914′, Journal of Contemporary History, 20 (1985).

G. Rosen, The Specialization of Medicine, with particular reference to ophthalmology (New York: Froben Press, 1944).

Whitwell’s brain slates

Part of the allure of studying Victorian science is stumbling across references to unusual – often slightly bizarre – pieces of equipment. Admittedly, an instrument for measuring the breaking strain of the ribs (see previous blog post) still ranks as one of the most unexpected devices, but my research this week has revealed another interesting innovation in the form of ‘Whitwell’s brain slates’.

Edwin Goodall, whose positions included Superintendent of Cardiff City asylum, produced a slim volume in 1894 entitled The Microscopical Examination of the Human Brain. In it, he advised the reader of the best means to preserve specimens for further study, and provided a list of the equipment needed for a typical asylum pathological laboratory. The autopsy room, for example, should include – as well as the ‘ordinary post-mortem apparatus’ – tables comparing the metric and English systems and Centigrade/Fahrenheit, a steel tape measure, ether-freezing microtome, and ‘Whitwell’s brain slates for recording lesions’.

Brain lesions were systematically recorded at many asylums in the late nineteenth century as interest in cerebral localisation – matching the loss of sensory or motor functions to lesions on the brain itself – grew, often by way of small printed diagrams of the brain which could be coloured in or annotated to denote the site of abnormal changes in the brain substance. Often, these were glued into post-mortem books to supplement the written record of the pathologist. Brain slates aimed to improve upon these paper diagrams:

‘MESSRS. DANIELSSEN & Co. have recently, at the suggestion of Dr. Whitwell, of Menston Asylum, made a set of engraved diagrams of the brain on slates for use in post-mortem and dissecting rooms. The diagrams are life size, twenty-five in number, and arranged on ten slates. The engraved outlines are filled in with white enamel, the Sylvian, Rolandic, and parieto-occipital fissures being, however, coloured red.’

Such slates were ideal for the post-mortem room, being marked ‘in chalk … by the pathologist even though his hands [were] soiled and wet’. The technical detail included in these slates was evident in the list of appearances they depicted, with a clear concern for recording the site of lesions as accurately as possible (though R. Percy Smith, reviewing the slates, expressed concern that their ‘general appearance [was] rather confused by the amount of detail’). Slate 6, for example, depicted a ‘Vertical section through the corpus callosum, anterior pillars of the fornix and optic chiasma; vertical section through the corpus callosum, optic thalamus and crura cerebri’.

It’s difficult to assess how widespread these brain slates were – there are few references to them in contemporary journals – and they were perhaps something carried by word of mouth from asylum to asylum (Edwin Goodall had previously worked at the Wakefield Asylum, one part of the larger network of Yorkshire asylums which Menston was also part of). Certainly though, they were symptomatic of much late nineteenth-century asylum practice, demonstrating the desire to document lesions of the brain in a specific manner, but also the desire to reveal the brain’s mysteries via post-mortem examination.

Further reading

Edwin Goodall, The Microscopical Examination of the Human Brain: Methods; with an appendix of methods for the preparation of the brain for museum purposes (London: Baillière, Tindall & Cox, 1894).

R. Percy Smith, ‘Brain Diagrams on Slates. (DANIELSSEN & Co., Beaumont Street, London, W.)’ [review], Brain 16 (1893).

                                                                                                                       -Jennifer Wallis