Tag Archives: post mortem

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’.

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

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

Bones, breaking strain, and the insane body in 19th-century asylum practice

In January 1870, author Charles Reade wrote to the Pall Mall Gazette to make some sensational claims about the conduct of asylum attendants. Whilst researching his book Hard Cash – in which a young man ends up confined in a lunatic asylum – Reade said he had seen alarming evidence of the tactics used by attendants to subdue the patients in their care. ‘The refractory patient’, he wrote, ‘is thrown down and the keeper walks up and down him on his knees, and even jumps on his body, knees downwards, until he is completely cowed.’ He thus suggested that he had hit upon the answer to a burning question of the day: how was it that so many patients in asylums seemed to sustain fractures?

Within the space of a few months, a number of cases were reported in which patients had been found to have extensive fractures at post mortem – one exhibiting an astonishing eight broken ribs and broken breastbone. The Pall Mall Gazette was not the only media outlet to voice its concerns about the care of the insane in Britain; an article in the British Medical Journal listed several instances of broken ribs, prompting a significant backlash from alienist members of the British Medical Association when it asserted that ‘rib-crushing, though the favourite, seems not to be the only mode in which lunatics are hurried out of existence … [In] 1869 a patient … was boiled in his bath’.

These were serious allegations, and the last quarter of the nineteenth century saw the issue of ill treatment in the asylum gain prominence. In the 1880s and nineties, with the development of training and certification for asylum nurses, handbooks advised staff on how to handle patients carefully, to spot the signs of fracture, and to subdue excitable patients who were especially vulnerable to injury.

The dialogue around broken bones also spread to the asylum laboratory, with some pathologists undertaking post-mortem tests to determine if the bones of the insane were inherently weak or brittle. Visual evidence of bone disease was mentioned in a number of articles on the topic: doctors and pathologists described bones that were ‘soft and boggy’ or ‘like sponge soaked in fat’. There was also a desire, though, to quantify such anomalous appearances more minutely. Theo Hyslop, when working as a Clinical Assistant at the West Riding Asylum, had used ‘an ordinary concrete testing machine’ to measure the strength of ribs at post-mortem. In 1893 Charles Mercier distributed a special instrument he had devised for the purpose. First, one ‘extract[ed] a certain length of the eighth pair of ribs’. Then, the lengths were put into the instrument, one tested against its concavity, the other against its convexity.The instrument ‘had a stirrup at one end and a screw at the other, and between these was a spring which registered the number of pounds pressure exerted. The bone … was put through the stirrup resting on the fork of the machine; the screw was then turned till the rib broke’. He sent this instrument to a number of asylums, as well as some London hospitals; though it is difficult to find much evidence of its use, it was certainly employed at length by Alfred Campbell at Lancashire’s Rainhill Asylum, who attempted to tabulate ‘breaking strain’ by type of mental illness.

Alfred Campbell’s results were most specific, confidently identifying an average breaking strain of 44.8lbs convex and 44.4lbs concave in his male general paralytic (neurosyphilitic) subjects, compared to 62lbs and 65lbs respectively in a healthy adult male. (Similar meticulous records of breaking strain can be seen in Francis Simpson’s Pathological Statistics of Insanity, where breaking strain by mental disease/sex etc. was recorded alongside brain weights.) Campbell’s second paper on the subject was more hesitant. Published only a few months later, this paper cast doubt on the link between fragile bones and insanity: ‘The difference between the average breaking strain of the ribs of the insane and that of the ribs of persons free from mental disease is not so great as one would anticipate’. In his comparative sample of 58 Rainhill Asylum patients and 50 Royal Southern Hospital patients, Campbell found very little difference between the rib breaking strain of the male asylum patient and that of the male general hospital patient. Explaining this, he theorised that wasting diseases had greater influence upon bone structure than mental afflictions – and indeed, many pauper asylum patients were in poor health.

Though the results of experiments like Campbell’s were often inconclusive and of little help to the living patient, the idea of bone fragility was incorporated into asylum administrative practices: at the West Riding Asylum, ‘breaking strain’ was consistently recorded at post-mortem from 1895 until around 1902.

Mercier’s instrument was not enduring in its impact: analysing 200 post-mortems at the West Riding, William Maule Smith in 1903 chose not to use it, instead basing his conclusions ‘on the ease with which fracture was produced by digital compression’ (Mercier, in the audience listening to Smith’s paper, unsurprisingly did not agree with Smith’s method!).

Bizarre as these experiments may seem to us now, the idea that the insane were peculiarly prone to bone disease and fracture was one that fitted logically alongside wider theories about both disease susceptibility and the general health of the asylum patient in the late nineteenth century. Quantifying rib strength did not, though, change the basic fact that patients were vulnerable individuals: the key figure remained the asylum attendant whose responsibilities were unchanged by the suggestion that some patients were especially liable to fracture. Via the lab then, the bones of the patient became capable of mediating not only asylum research, but also everyday practices and social relations – objects both constructed and constructing, and a sign that the insane body was not a merely passive one, even in death.

Further reading

Anonymous, ‘A social blot’, British Medical Journal (22 Oct. 1870).

Alfred W. Campbell, ‘The breaking strain of the ribs of the insane: an analysis of a series of fifty-eight cases tested with an instrument specially devised by Dr C.H. Mercier’, Journal of Mental Science 41 (1895).

Alfred W. Campbell, ‘A comparison between the breaking strain of the ribs of the sane and insane’, British Medical Journal (28 Sept. 1895).

W. Lauder Lindsay, ‘Mollities ossium in relation to rib-fracture among the insane’. Edinburgh Medical Journal 16 (1870).

Charles Mercier, The Attendant’s Companion: a manual of the duties of attendants in lunatic asylums (London: J & A Churchill, 1898).

George H. Pedler, ‘Mollities ossium and allied diseases’, in James Crichton-Browne (ed.) West Riding Lunatic Asylum Medical Reports 1 (London: J & A Churchill, 1871).

Charles Reade, ‘How lunatics’ ribs get broken’, Pall Mall Gazette 1541 (20 Jan. 1870).

Francis O. Simpson, The Pathological Statistics of Insanity (London: Baillière, Tindall & Cox, 1900).

William Maule Smith, ‘On the nature of fragilitas ossium in the insane’, British Medical Journal (3 Oct. 1903).

– Jennifer Wallis