Tag Archives: pathology

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’.

A ‘new’ disease?

At the November and December meetings of the London Clinical Society in 1884, an interesting debate unfolded: was a ‘new’ disease appearing in England? A number of patients had been seen in hospitals and asylums in the preceding years who exhibited unusual joint affections. It was a sudden phenomenon, characterised by severely swollen but usually painless joints. Though any joints of the body might be affected, knees and ankles tended to fare worst. The lack of pain and generally dulled sensations that were experienced impacted on the everyday actions of sufferers, who dropped objects, frequently fell, or had difficulty walking. Other bodily manifestations appeared in the form of ulcers, often on the feet. Many patients also reported that they suffered from ‘neuralgia’, ‘flying gout’, and gastric crises.

Deformity of the knee in Charcot's disease. © Wellcome Images/St Bartholomew's Hospital Archives & Museum.

Deformity of the knee in Charcot’s disease.
© Wellcome Images/St Bartholomew’s Hospital Archives & Museum.

The condition was first properly identified by neurologist Jean-Martin Charcot in 1868, earning it the moniker ‘Charcot’s joint’ (Charcot noted that the condition had also received attention from J.K. Mitchell in the 1830s). In 1880s England, though, according to W. Hale White of Guy’s Hospital, ‘discussion about Charcot’s joint [had] waxed very warm’. Alienist interest in the condition stemmed from its appearance in tabes dorsalis (nerve degeneration in the spinal cord due to untreated syphilis) patients, who were often seen in asylums before the incidence of syphilis was vastly reduced with the use of penicillin in the 20th century. Charcot said he had only ever seen the condition in tabes dorsalis patients, and other asylum doctors related similar cases. Conolly Norman at Dublin’s Richmond Asylum hosted a meeting of the Irish division of the Medico-Psychological Association in 1896 at which delegates viewed two cases of Charcot’s joints on Richmond’s wards, both occurring in general paralytic (neurosyphilitic) patients. In syphilitic conditions, nerve degeneration impaired patients’ reflexes and sensations whilst muscle wastage reduced the natural protection around the joints. The result was that patients became increasingly vulnerable to injury (discussions of the disease often noted spontaneous fractures), or their bones literally ‘wore away’ as they ground together.

L0061441 Dissected knee joint, the subject of marked locomotor ataxy

Dissected knee joint exhibiting Charcot’s disease.
© Wellcome Images/St Bartholomew’s Hospital Archive & Museum.

Alongside syphilis, physical injuries were also cited by some as an immediate, exciting cause. (Whilst syphilis was the condition most commonly associated with Charcot’s disease by nineteenth-century doctors, it was gradually recognised as a condition with much wider aetiological factors. It may be present in diabetic neuropathies, for example, where nerve damage affects the weight-bearing joints.) J. Wallace Anderson related the case of a patient at Glasgow Royal Infirmary. Admitted to the hospital due to his difficulty in walking, the 45 year old gardener ‘ascribe[d] his complaint to a stroke of lightning … twelve years ago’, following which he began to experience ‘tingling’ pains and weakness in the hips, until finally his right hip “went out”. Though he was discharged from the hospital able to walk with the aid of sticks, he remained prone to ‘unusual variations in his general condition’. Charcot’s disease was, ultimately, untreatable, and little could be done for patients other than try to assist their mobility in various ways.

N0008052 Charcot's knee

X-ray of a Charcot’s knee.
© Wellcome Images.

Ascertaining if Charcot’s disease was indeed novel to the late nineteenth century was difficult. One stumbling block was the apparent lack of such specimens in pathological museums: if it wasn’t a new disease, why were there no samples from previous years? At the London Clinical Society meeting, Sir James Paget suggested that museum curators – even if they were able to secure a specimen of a comparatively rare condition – tended to collect normal rather than abnormal specimens for teaching purposes. Interpretations of the disease ranged from osteo-arthritis to ‘modified’ chronic rheumatic arthritis, though such diagnoses were complicated by the sudden onset of the joint affection.

Although W. Hale White said that discussion about the disease had ‘waxed very warm’ and ‘everyone [had] had an opportunity of expressing his opinion’, he doubted if ‘exact knowledge of the subject [had] been much advanced’. At a point in time when doctors were increasingly keen to pinpoint the physical lesions of disease, Charcot’s joint seemed a perfect opportunity to trace a visible physical deformity to minute changes in the nerves. This was complicated by its resemblance to other conditions, however: was it just a form of rheumatism? Was it a ‘new’ disease? Or a ‘new compound of diseases’? These were – and are – fascinating questions that bring to mind current historical debates about retrospective diagnoses, the ‘framing’ of disease, and how we assess medical knowledge of the past: giving a condition a name didn’t necessarily mean that its identity was static, or signal a ‘pinnacle’ of understanding.

Further reading

D. Ferrier, On Tabes Dorsalis: the Lumelian Lectures, delivered before the Royal College of Physicians, London, March, 1906 (London: John Bale, son & Danielsson, 1906).

W.J.M.A. Maloney, Locomotor Ataxia (Tabes Dorsalis): An Introduction to the Study and Treatment of Nervous Diseases, for Students and Practitioners (London: D, Appleton, 1918).

L.C. Rogers et al, ‘The Charcot Foot in Diabetes‘, Diabetes Care 34 (2011).

L.J. Sanders, ‘Jean-Martin Charcot (1825 – 1893): The Man Behind the Joint Disease‘, Journal of the American Podiatric Medical Association 92 (Jul./Aug. 2002).

H. Waldo, ‘A Case of Charcot’s Joint Disease, with Perforating Ulcer of the Foot in a Tabetic Patient‘, BMJ (1 Dec. 1894).

R. Waterhouse, ‘Remarks on the Arthropathies of Acquired Syphilis‘, BMJ (10 Oct. 1908).

A mystery object

Amidst the records of one nineteenth-century asylum, a ‘Pathological lab scrapbook’ documents the interests of the asylum doctors in a striking visual narrative of limb deformities, brain sections, and photomicrographs. You can read more about that scrapbook here, but today I’m issuing you a challenge: do you know what this item is, below?

It appears towards the end of scrapbook, stuck to a page with no accompanying explanation, but likely dates to the 1890s. Is it something akin to Volkmann’s spoon, used to delicately remove diseased tissue or bone? Or is it something completely unrelated to scientific endeavours, stuck into the book by a playful doctor? Please leave your suggestions in the comments box below – I’d love to know what this is!

- Jennifer Wallis