Post-mortem in the Victorian asylum: practice, purpose and findings at the Littlemore County Lunatic Asylum, 1886–7

Abstract

This article examines the purpose of the post-mortem in the late Victorian asylum and discusses what the findings reveal about contemporary understanding of mental health. By examining the practice at the Littlemore Asylum of Oxford, the definition of the asylum post-mortem will be questioned and issues of consent and ownership of the dead body explored. It will be argued that the purpose of the examination was partly to appease the demands of the Commissioners in Lunacy, to protect the asylum against accusations of malpractice, and to appease the resident assistant medical officer’s own morbid curiosity. The examinations would therefore be better defined as dissections. This article will challenge understanding of institutional death, the legal processes required for dissection, and mental healthcare.

Introduction

During the 1880s, the death rate at the Littlemore County Lunatic Asylum of Oxford stood at approximately 10% of the total number of inmates (Oxfordshire Health Archives (OHA) Reports of the Committee of Visitors (RCV), 1887: 8, 18). Of those 57 deaths, 55 underwent post-mortem examinations (p. 23). This figure is substantially greater than the already high national average of post-mortems conducted in county asylums across England and Wales, which by 1885 was just over 70% of all deaths (Parliamentary Papers (PP) Commissioners in Lunacy: Fortieth Annual Report to Lord Chancellor (CL 40), 1886: 46). The post-mortem was part of the fabric of the asylum system, and yet the practice, purpose and findings of the examination in the asylum setting have only begun to receive academic attention in the last few years and are still seriously under-studied in the historiography of mental healthcare. Some of the most significant works on the subject to date include those of Andrews (2012), MacDonald (2011), MacKinnon (2011), and Wright, Jacklin and Themeles (2013). MacDonald has discussed questions of consent with regard to the dissection of asylum bodies in Australia and Britain, while MacKinnon’s work on dissecting the mad in Colonial Victoria (Australia) highlights the lack of work on post-mortems within the history of psychiatry and examines the fate of asylum bodies. Andrews’ work on the Royal Edinburgh Asylum explores the meaning of the post-mortem within the asylum and its dead-house in Scotland. Wright and colleagues have examined mortality regimes and cause of death data at four asylums in Ontario (Canada), questions surrounding ownership of the dead body, and resulting tensions between asylums’ medical schools throughout the latter half of the nineteenth century. These works have all helped to place the asylum post-mortem in the wider historiography of mental healthcare worldwide. The practice in England, however, has yet to be empirically examined.

It is important, therefore, to examine the post-mortem in the English asylum in order to gain a better understanding of the place of the procedure in late nineteenth-century medicine and law, and to contribute to the current literature. The practice and purpose of examining the body differed between asylums, and so more research is needed to build a comprehensive picture of how these institutions treated their dead. There have been few empirical studies of post-mortem findings, so we know little of the ill health of the patients and how contemporaries understood physical signs of madness on the body. This article will contribute to the limited historiography by considering the practice of performing the post-mortem in an English pauper asylum during the late nineteenth century, which no previous work has examined. The case study will contribute towards our understanding of the asylum post-mortem by examining the first year of accounts in the Post Mortem Examinations Book (henceforth OHA PMEB) of the Littlemore County Lunatic Asylum (LCLA) in Oxford, a unique first-hand account of post-mortem findings in 1886–7. These dates are significant, as these records coincide with broader changes in the Poor Law system that resulted in more people entering asylums. The Poor Law Medical Relief (Disqualification Removal) Act 1885 was passed to remove the stigma of Poor Law medical treatment, by giving voting powers to the poor relief medical claimants. This resulted in many guardians of the poor attempting to find cost savings in medical care and cancelling any remaining medical out-relief entitlements, which subsequently would have forced more people into asylums (Hurren, 2004).

This article will first discuss the practice of examining the dead body at the Littlemore and the creation of the PMEB. The examination of the dead has attracted plenty of focus in the wider historiography (Behlmer, 2003; Harley, 1994; Hurren, 2004, 2008, 2011a, 2011b; MacDonald, 2006, 2009, 2011; Richardson, 1987; Strange, 2002, 2005). The history of the post-mortem has most frequently been discussed in relation to the development of hospital medicine and the newly resulting science of pathology, credited to the clinicians of the French Revolution from the late eighteenth century onwards (Ackerknecht, 1967; Bynum, 1994; Foucault, 1973; Granshaw and Porter, 1989; Porter, 1999; Waddington, 2011). The modern post-mortem gave clinicians a way to ‘objectify the phenomena of disease, and thereby replace the speculations of 2,000 years with the hard, palpable, visible, weighable, material consequences of pathology’ (Bynum, 2008: 54). The PMEB dates from 1886 and was compiled by the resident Assistant Medical Officer, Frederick William Pilkington. Its structure and layout will be discussed first, and then the purpose of the examination and the record book will be assessed. Questions surrounding the definition of an asylum post-mortem, and consent for its performance, will be explored in relation to the wider medico-legal scene in which the coroner operated. Our knowledge of the relationship between the coroner and medical health care institutions, particularly asylums, is lacking. In the nineteenth century, overlapping and sometimes contradictory legislation, including the coroners Acts, lunacy laws and anatomy Acts, meant that the process of recording, storing, examining and burying deceased asylum patients was subject to interpretation. The immediate issue of a notice of death provided by the asylum to the coroner meant that he was aware of all instances of death, although technically he was only required to examine a body if the cause of death was thought to be suspicious or violent. At the LCLA, we will discover that the asylum staff frequently issued a notification of death to the local coroner before performing the post-mortem. The purpose of these examinations was therefore not to determine cause of death. This article will therefore explore the true purpose of these examinations at the LCLA and question the coroners’ knowledge of their performance. I will then turn to the contents of the PMEB and the findings of the examinations. Patient information will be examined in order to gain a better understanding of who was treated and dissected at the pauper asylum during the late nineteenth century. Details in the records include patient names and sex, and further information can be gained in some cases by linking post-mortem records to corresponding patient case records. The main causes of death will then be analysed and examined alongside the content of the records, in order to determine how mental health was perceived and diagnosed on the body.

The Post-Mortem Examinations Book

Wright et al. (2013), writing on mental hospitals in Canada between 1841 and 1891, discuss the value of asylum documents as an historical source, and they highlight how little work has addressed or made use of them. Some of the most extensive publications examining asylum documents are those of Andrews (1998, 2012), who has studied the Scottish patients’ experience of insanity and death in the asylum. His work on the Royal Edinburgh Asylum claims that the Resident Physician, David Skae (1846–73), may have been ‘the first among Scottish royal asylum physicians to introduce separate post-mortem record keeping’ (Andrews, 2012: 10). As an examination of the post-mortem book of a pauper asylum in Oxford, England, the present study both contributes to the international debate of death in the Victorian asylum and places an example of the English experience into that debate for the first time.

Much has been written on the general history of the lunatic asylum (Andrews and Scull, 2003; Bartlett, 1999; Bynum, Porter and Shepherd, 1988; Crammer, c.1900; Digby, 1999; MacDonald, 2011; McGrath, 1997; Porter, 1987; Scull, 1979; Smith, 1999; Waddington, 2011: ch. 16; Wright, 2001; Wright et al., 2013). However, the Littlemore has only once before been the focus of academic study, in Yorston and Haw’s (2005) paper on patients aged 60 and over in the Oxford asylums of the nineteenth century. The average number of patients at the LCLA, which was founded in 1846, gradually increased from 200 in 1848 to well over 500 in 1900 (p. 398). The PMEB details the appearance of the dead body and the recorded cause of death. Post-mortems would have been performed in asylums for decades prior to the 1880s (PP CL 40, 1886: 46; e.g. Andrews, 2012; Anon., 1878), so it is not known whether this is the earliest post-mortem book of the Littlemore to survive, or whether it represents the beginning of post-mortem reporting at this asylum. It would appear to be no coincidence, however, that the book appeared directly after the Lunacy Acts Amendment Act (LAAA) of 1885, which sought in part to protect the medical profession from charges of negligence (Bodleian Library (BL) LAAA, 1885). Earlier lunacy legislation had already given instruction, in the event of the death of an asylum inmate, to send a notice to the coroner, in the same manner as other institutions of the period (BL LAAA 1862).¹ The English asylum system was overseen by the Commissioners in Lunacy from 1845, and they also required notification of a date and cause of death from the asylum (Wright et al., 2013: 603). The 1885 Act encouraged more transparency in the profession, and so probably led to post-mortem reporting. The PMEB was not produced for this purpose, however, as the rules of a standard patient case book were printed on the first page (OHA PMEB: i). It would therefore appear to be the product of a speedy reaction to the Act of 1885.

The basic structure of the PMEB was established from its beginning. The name of the patient, time and date of death and of the post-mortem examination are recorded, followed by the external appearances of the body, details of the cranium, brain, heart, lungs, liver, kidneys and spleen, and the cause of death (e.g. OHA PMEB, Edwin Hunt, 9 Mar. 1886: 1). In the third report, the bladder was included in the examination (OHA PMEB, Emma Coe, 12 Mar. 1886: 4) and also in all cases that followed. Similarly, in the fourteenth report the uterus was recorded for the first time and later the ovaries and other genito-urinary parts were described (although these were not always included in subsequent reports) (OHA PMEB, Martha Beale, 21 May 1886: 24–5). As post-mortems had been performed at the Littlemore prior to the creation of the record book (e.g. Anon., 1878), the inclusion of new body parts in the basic structure of the reports either represents real practical developments in how the procedure was conducted, or a development in what was considered worthy of reporting. It was most probably a mixture of both, given that compulsory recording would have encouraged a more thorough examination.

In the first year post-mortem records, 60 examinations were performed at the LCLA. The monthly Reports of the Committee of Visitors state that in 1886 57 patients died in the asylum, and 51 in 1887 (OHA RCV, 1887: 18). The proportions of deaths in the average numbers of residents were 11% and 10%, respectively (OHA RCV, 1886: 8, 1887: 9). Of the 57 deaths in 1886, post-mortems were carried out on 55 inmates (OHA RCV, 1886: 5). Additionally, of the 80 inmates who died between 31 May 1886 and 18 October 1887, post-mortems were carried out in 74 cases (OHA RCV, 1887: 9). From these figures it is clear that the 60 patients recorded in the first year of the PMEB represented the majority of the total number of deaths at the asylum. Indeed, by 1885 post-mortem examinations were carried out on over 71% of all deaths in county asylums across England and Wales (PP CL 40, 1886: 46). Pressure from the Lunacy Commission and the demands of medical education meant that many asylums were performing the examination on the majority of their deceased.

The practice of post-mortem at the Littlemore

Definition

The post-mortem examinations were carried out at the Littlemore by the resident Assistant Medical Officer, Frederick William Pilkington, L.R.C.P. London, M.R.C.S., England (OHA RCV, 1887: 5). Clearly a valued member of the Littlemore staff, in the Committee of Visitors Report of 31 May 1886 Pilkington is credited by the Resident Medical Superintendent R.H. Heurtley Sankey for his intellect and reliable assistance (OHA RCV, 1886: 15). Nevertheless, the fact that the examinations were performed by the resident medical man raises issues of definition and reliability. The term post-mortem is frequently interchanged or confused with autopsy or dissection, but there are generally accepted differences between these procedures. Hurren (2016) explains that autopsy meant to look at or observe, generally only the surface of a dead body, while anatomization was to open up the body with the cross-shaped incision made down the torso and across the chest in order to examine the major organs, stomach, and womb or male genitals. The body was then sewn up. In the eighteenth century, this was known in medical circles as splanchnology. Dissection was the extensive cutting of the body and the dismemberment of the body parts. It would have begun as anatomization and proceeded to dissection. While anatomization was sometimes seen in a public space, dissection was seldom done in anything but a private medical one. Post-mortem is, then, a generic term for these options. It was a staged process and a carefully choreographed one, depending on concern about the cause of death.

Moreover, MacKinnon (2011: 79) defines the post-mortem examination as one which should be called by the coroner. In this sense, the post-mortem demands a higher standard of institutional healthcare, by questioning the cause of death. The coroner’s post-mortem has been the focus of the works of Burney (2000), Fisher (2007), Forbes (1978), Hurren (2009) and Zuck (1995). The ascendancy of pathology and forensic medicine during the nineteenth century increased the viability and use of the post-mortem examination in the British legal systems (Forbes, 1978; Waddington, 2011). Hurren’s work on the late-Victorian coroner in Oxford states that by the nineteenth century there were approximately 300 coroners in England and Wales responsible for investigating around 5–7% of deaths annually (Hurren, 2009). Forbes and Zuck have both examined the changing role of the coroner and the system of inquest, though according to Hurren and Fisher there is still a lack of understanding as to the operation of the office. According to the Lunacy Acts Amendment Act of 1862, on the event of a death in an asylum, ‘transmit [the statement] to the Coroner of the County or Borough, the same … as is required by Law to be transmitted in the Case of the Death of any Patient in any Hospital or Licensed House’ (BL LAAA 1862). It would then be the coroner’s responsibility to call an inquest if he considered the stated cause of death to be unsatisfactory or the circumstances to be suspicious (BL LAAA 1862; Burney, 2000; Zuck, 1995).

Each of the post-mortem reports of the Littlemore contains a copy of a notice of death sent to the Coroner of the Central District of the County of Oxford, Mr William W. Robinson Esq., a solicitor who held the position from 1877 to 1905 (Kelly’s Directory, 1906). Burney (2000) has discussed the debate coined the ‘Post-mortem Question’ of the late nineteenth century, which asked who ought to carry out the examination as requested by the coroner: a specially trained pathologist, or the physician who treated the patient at the end of their life. It was argued that a pathologist would examine the body objectively and provide a cause of death based purely on the signs on the body, while the physician who treated the patient at the end of their life would approach the post-mortem table with a cause of death already in mind. Arguably, only the examination carried out by an objective pathologist could be called a post-mortem, while the subjective examination performed by a medical man attached to the case would better be defined as an autopsy or dissection, sanctioned under anatomy legislation, usually for the purpose of medical education (MacKinnon, 2011). By the turn of the twentieth century, coroners such as Mr Troutbeck of London were demanding that pathologists be entrusted to conduct post-mortem examinations in order to conclude an objective and reliable cause of death (Zuck, 1995).

MacKinnon (2011) found that the coroners’ procedure for conducting post-mortems varied across asylums. At the LCLA only one inquest was called by Robinson over the duration of the record book, meaning that the examinations performed at the asylum were not coroners’ post-mortems (Anon., 1886; OHA RCV, 1887: 8–9). Moreover, the death notices issued to Robinson were often dated before the post-mortem had taken place. This meant that the asylum provided the coroner with a cause of death and then proceeded to conduct an internal examination of the body. In one such case, the death notice of a female inmate was sent to the coroner on the day the patient died, stating the cause of death as senile decay and epilepsy (OHA MCBF, Mary Cooper, 7 Feb. 1884: 148). The post-mortem was conducted two days later (such a wait was not uncommon in winter months, as the body could be kept cold enough to delay the process of decomposition). The examination found that the lungs contained ‘numerous small masses of tubercle’, confirming the presence of tuberculosis or another lung complaint. The post-mortem report stated that the cause of death was epilepsy and the lung complaint pulmonary hypostasis (OHA, PMEB, Mary Cooper, 10 Jan. 1887: 101–4). Although an aspect of the cause of death was found to be different from the notice sent to the coroner, there is no evidence that an amended notice was sent. As these examinations were clearly not to determine the cause of death and were performed by the asylum assistant medical officer, Pilkington, it would be more appropriate to refer to them as dissections.

Consent

These dissections were not called for by the coroner, so consent (or lack of it) for conducting such examinations must have come from elsewhere. Whether or not asylums like the LCLA had permission to carry out these examinations has been the focus of debate in the current historiography. Andrews (2012) and Wright et al. (2013) have discussed the disparities in consensual post-mortem practice across asylums. When a person who was not in an institution died in the late nineteenth century, if the cause of death was considered by the coroner to be unknown or suspicious he would call for a post-mortem examination to be undertaken and an inquest to be held. However, when a person died in an asylum during this period, it was not clear who owned the body and who was allowed to examine it (Wright et al., 2013). Unclear and conflicting anatomy, lunacy and coroner legislation meant that ownership of the dead body could technically belong to the State, the institution or the family (Andrews, 2012; Wright et al., 2013).

Andrews has highlighted the disparities in seeking post-mortem consent between different asylums. In some, it was the decision of the deceased’s family or friends after death had occurred. In other institutions, such as Guy’s Hospital, post-mortems were compulsory unless formal objection had been made by the patient’s family or friends prior to death (Andrews, 2012; MacDonald, 2011). Religious fears would have been a strong factor for many families in refusing post-mortem on a family member (Andrews, 2012; Behlmer, 2003; Strange, 2002). The laying out and funeral of the body in its entirety was considered necessary in order for the deceased to secure a place in the afterlife. Fears over the prospect of dissection are likely to have weighed heavily on the minds of the patients themselves. Andrews (2012) states that paupers at the Royal Edinburgh Asylum were probably employed to make coffins and shrouds, and this made the idea of death ever-present in the inmate’s life. This may also have made their families even more sympathetic to their relatives’ fear of dissection. Hurren (2008) has suggested that at some hospitals a patient’s funeral expenses were paid for in exchange for the family allowing a post-mortem. This may have occurred at some asylums in order that a family member was not buried in the asylum burial grounds. In many instances, however, the patient may not have had any family to object. Overall, Andrews (2012) argues that by the 1880s asylums were conducting post-mortems on all their deceased, and relatives were less likely to object, although there was still strong resistance.

At the Littlemore, gaining consent for performing post-mortem dissections appears not to have been straightforward. In 1878 an article was published in Jackson’s Oxford Journal entitled ‘Littlemore Asylum: inquiry into the death of a patient’, in which asylum staff defended the performance of a post-mortem on the patient John Simms which had not been called by the coroner (Anon., 1878). Mr Sankey, the Medical Superintendent, stated that ‘in the event of death, the remains of a patient are examined, unless previous written notice to the contrary shall have been sent to the Superintendent. This notice is always given to the friends, and in the case of John Simms the custom was followed’ (Anon., 1878). It was claimed that this notice was always given to friends or relatives of the patient on their admission, not at the time of death. In the case of Simms, the staff said that a notice of death was sent to the coroner and to the family of the deceased on the day of death, the cause of death having been determined as epileptic exhaustion, and the post-mortem was not performed until that evening. This was arguably still an insufficient amount of time for any last-minute objections to be heard. Sankey seemingly defended the performance of the post-mortem on the basis that ‘The Commissioners (in Lunacy) are always asking us to make post-mortem examinations as often as it is possible to make them … The Commissioners have thought that this was quite a proper thing to do’. In this case, the inquest resolved that:

the Superintendent did not exceed his duty in examining the body post-mortem without waiting for the order of the Coroner, as that duty is indicated by the system and practice encouraged and sanctioned by the Commissioners in Lunacy and the Superintendent having given to the relatives of the deceased, on his admission as a patient, the usual printed notice that ‘in the event of death, the remains will be examined, unless previous written notice to the contrary shall have been sent to the Superintendent’. (Anon., 1878)

The examination of the dead at the asylum was therefore defended on the grounds that it was called for under lunacy legislation. It was noted in the article, however, that the practice of holding post-mortem examination irrespective of an order from the coroner needed attentive investigation at the hands of the Littlemore Asylum Visitors (Anon., 1878). Although this case was eight years before the creation of the PMEB, it would appear that the rules governing post-mortem consent had not changed by 1886. Overall, the percentage of patients dissected at the LCLA increased between these periods, suggesting that the asylum gained consent to examine more bodies (Anon, 1878).² Whether this consent was directly gained from the patient’s friends and family, however, remains unclear. Ownership of the dead body and post-mortem consent were clearly still unresolved grey areas in nineteenth-century law and medicine.

This 1878 article highlighted the question of the definition of the examinations of the dead taking place at the Littlemore. The inquest of Simms concluded that the examinations were legal, but that the practice without consent from the coroner needed to be addressed. It has been established that the examinations at the Littlemore would be better described as dissections. However, as discussed above, it would appear that the legality of the practice came under overlapping and conflicting lunacy, anatomy and coroner legislation (MacKinnon, 2011: 76–89).³ This raises the question as to how these laws could co-exist to govern the practice of examining the dead in institutions like the Littlemore. One possible explanation could be the long-established ‘Gentlemanly agreements’ held between coroners and practitioners, discussed by Zuck (1995). He argues that, because many coroners had held their office for long periods, ‘local accords between coroners and general practitioners did not always work to benefit the public’ (p. 260). In many cases, they held relationships based on ‘Gentlemanly agreements’, whereby physicians tended to be left to examine the dead body without the involvement of the coroner (p. 264). Zuck explains that, by the turn of the twentieth century, the coroner would call a separate pathologist to conduct the post-mortem instead of the physician in the institution where the patient died, thus ending the system of ‘Gentlemanly agreements’ (pp. 264, 286). However, the coroner must have been aware of dissections taking place, in addition to those called for inquest. In cases like the Littlemore, the coroner Mr Robinson must have known that Pilkington was dissecting the majority of the dead, but was not challenged unless an inquest was deemed necessary. The coroner clearly knew of the demands for dissection and understood that he could not police the practice on such a large scale.

Purpose of dissections at the Littlemore

The purpose of examining the dead body in the asylum setting has most frequently been attributed to the demands of medical education and the search for the physical evidence of madness on the body (MacDonald, 2011; MacKinnon, 2011). Andrews’ work on the Royal Edinburgh Asylum suggests that the purpose of the asylum post-mortem was for ‘clarifying doubts over causes of death, the wider pursuit of psychiatric knowledge, the production of mortality statistics, or satisfying central Lunacy Commission watchdogs’ (Andrews, 2012: 9). The Commissioners in Lunacy pushed for asylums to conduct post-mortems on as many bodies as possible, in order to advance the understanding of mental illness. The language contained in the post-mortem reports of the Littlemore, however, does not suggest that they were written with educational purposes in mind. They were often sparsely filled out with minimal detail about each organ and using informal, non-medical language. Body parts are described as being the ‘size of an orange’ or nodules the ‘size of a millet seed’ (OHA PMEB, Agnes Sarah Caless, 28 Apr. 1886: 20; Kate Elderfield Jones. 20 Feb. 1887: 122). In one case, the liver is described as being of ‘nutmeg appearance’, while in others bodily liquids are described as ‘oozing’ from the cadaver (OHA PMEB, Harriet Crompton, 24 Apr. 1886: 19; James Mold, 16 Nov. 1886: 75). The use of such subjective language appears to be for Pilkington’s own personal recollection rather than for the benefit of a medical audience. There is also no mention in the records of any body parts or specimens having been kept for educational reference, nor can any evidence be found that Pilkington published any of his findings from his dissections. It would therefore appear that he made no attempt to contribute towards the wider medical understanding of mental health through his examinations of the insane dead. He may well have been fulfilling his own personal curiosity as to the appearance of madness on the body, but he did not share any knowledge he gained.

As discussed above in the ‘Post-Mortem Examinations Book’ section, the 1885 Lunacy Acts Amendment may have been the driving force behind the creation of the PMEB at the Littlemore. The practice of recording the examinations of the dead would have acted as a means of protection against claims of negligence or malpractice against asylum staff. Pilkington often began his reports by defending the treatment the patient received under his care. Bodies are recorded as having ‘no sores or injuries’ or ‘no bruises or discolouration’, as a means of expressing the non-violent treatment they received in life (examples include: OHA PMEB, William James Brown, 12 Mar. 1886: 3; Harriet Harrison, 15 Mar. 1886: 5). Fear of malpractice accusations would have come from cases such as the ‘broken rib scandal’, described by Wallis (2013). From the 1870s, a number of deaths in asylums were blamed on asylum staff; as a result, the fractures found on patients’ bodies after death were ascribed to bone fragility brought on by particular forms of insanity, rather than violent methods of asylum control (Wallis, 2013). By stating in the first instance that a body was free from injury, Pilkington cleared himself and the asylum of any mistreatment or blame associated with the cause of death.

It would appear, then, that Pilkington was performing and recording dissections at the LCLA partly to appease the Commissioners in Lunacy and partly to protect the asylum against any accusations of malpractice. While apparently wasteful, it was not uncommon for medical officers to withhold their findings from the wider medical community, and this did not go unnoticed. Mackinnon (2011) has pointed to the contemporary opinion that ‘the valuable material of the post-mortems and entries in the case books’ continues to be wasted, and no one except the medical officer of the asylum profits by the large and varied experiences’ (p. 104). Asylums performed large numbers of post-mortem examinations, but it was recognized that minimal original papers or scientific discoveries came from them (MacKinnon, 2011). Pilkington also made no attempt to sell any of the bodies to medical science. While it would appear that asylums did not make it common practice (and certainly not a well-known practice) to sell bodies to medical schools during the late nineteenth century, demand for corpses to complete medical education was high (MacKinnon, 2011; Wright et al., 2013). It was not illegal for asylums to sell bodies, but there was a feeling of unease about the practice until the twentieth century. Wright et al. (2013) point to the governors of Norfolk County Asylum, who opposed the superintendent’s request to send bodies to Cambridge University’s School of Anatomy around the turn of the century. Other asylums were selling bodies during this period, however, as highlighted by Andrews (2102) in his work on the Royal Edinburgh Asylum, which sent between one and fourteen bodies annually to Edinburgh’s medical schools between 1853 and 1890. In her extensive work on the subject, Hurren (2008, 2011a: 73) has shown that Oxford medical schools received lunatic bodies from the Leicester Poor Law Union, as it could presumably not purchase bodies close by, for example from the Littlemore.

The findings of dissection

While the practice of performing the post-mortem in the asylum setting has been discussed in the current historiography, any empirical examination of post-mortem findings has been limited. The contents of the PMEB provide a unique insight into the mental and physical health of the asylum inmate and into the contemporary medical knowledge of madness. The deceased who appear in the book range in age and background, as was often the case in the asylum setting (Andrews, 1998; Wright et al., 2013). According to the Littlemore Visitors Committee Report of 1886, the most common age for a patient to die was between 65–70 years, although in the first year of the PMEB the age range was 30–78 years (OHA RCV, 1886: 26; PMEB). Many of the deceased came to the Littlemore from other asylums and workhouses. Thomas Elder was admitted on 5 August 1884 from the Colney Hatch Middlesex County Asylum, having previously been a member of the St. Pancreas Workhouse (OHA Admission Orders (AOs), Thomas Elder, No. 4905). Others came to the asylum from local towns, including the Unions of the City of Oxford, Abingdon, Chipping Norton, Woodstock, Witney and Henley (OHA Admission Register (AR), 1886). The religion of the patients was recorded on admission, most people belonging to the Protestant faith (OHA AOs). Religious affiliation would have been noted by the staff in order to provide relevant care and better understand the patients’ mental conditions (Andrews and Scull, 2003). The most common previous occupation of male inmates was labourer, and of female inmates, housewife, neither of which is surprising given that the Littlemore was a county pauper asylum (OHA RCV, 1887: 27). The total number of inmates in the asylum at the turn of 1887 was 493, of whom 216 were males and 277 were females (OHA RCV, 1887: 7). These figures followed the national trend of more females in county asylums than men, who made up the larger population in private asylums (Showalter, 1980). Of the 60 post-mortem accounts recorded in the record book, 22 cases were male and 38 female (OHA PMEB; RCV, 1886: 17, 1887: 7).⁴ These figures show that the death rate of patients was higher among females than males in proportion to the total numbers of each sex in the asylum. This is in contrast to the claim by Showalter (1980) that the female mortality rate in county asylums was lower than that of males.

The most common causes of death recorded in the reports were the collective types of lung disease, followed by general paralysis of the insane, epilepsy, dementia and mania. Before these are examined, it is important to discuss the primary focus of each report: the appearance of the brain. Given that these were dissections of the sectioned insane, concern with the brain is not surprising. While Professor Ferrier of the Anthropological Institute claimed in 1887 that the ‘physiological aspects of brain-functions were still far from being made out’ (Ferrier, 1887), Andrews (2012) states that although most alienists acknowledged certain limitations to post-mortem research, many still believed that mental health could not exist without a morbid change in the brain.

At the Littlemore, the influence of phrenology can be seen in the post-mortem reports. Phrenology separated different areas of the surface of the head and their corresponding areas of the brain into different organs of personality and mental capability (Porter, 1999; Waddington, 2011). For example, the cerebellum was believed to be the ‘seat of the memory, or that of the so-called higher intellectual facilities’ (Franz, 1912; Waddington, 2011). By the late nineteenth century, conclusions drawn by phrenology were often used to make arguments about heredity and degeneration (Waddington, 2011). Statements such as an ‘adult male head of only nineteen inches circumference is utterly incapacitated for any bread-earning occupation’ – found in Donovan’s A Handbook of Phrenology (1870: v) – were common, and fostered wider concern in the state of the workforce. Pilkington frequently reported on the shape of the head; for example, in the case of William Turner the ‘forehead is prominent and large, head larger than normal’, while in that of Letitia Long the ‘skull cap oval in shape, regular in outline’ but the ‘brain substance as a whole is greatly increased in density and consistence’ (OHA PMEB, 24 Dec 1886, William Turner: 91–2; Letitia Long: 94). The weight and general appearance of the brain was then recorded, before it was preserved for detailed examination and divided into the two separate hemispheres, and the cerebellum, pons and medulla. The weight of the brain was believed to be a direct indication of intelligence or insanity. According to the work of Ross (1925), the average brain size of a female was 44–45 ounces, and for a male 48–51 ounces. Many of the brains examined during the post-mortem would have been considered small and inferior, such as that of Thomas Elder, who Pilkington reported to have died of dementia, as the brain was reported to have been undergoing ‘degeneration’ and weighed only 41½ ounces (OHA PMEB, Thomas Elder, 8 Aug. 1886: 47–9).

Congestion of the lungs

Afflictions of the lungs in the lower classes were often attributed to poverty and poor living conditions, and their prevalence in the asylum reflected that in the wider population during the late nineteenth century (Andrews, 2012; Wright et al., 2013). At the Littlemore, Pilkington diagnosed lung complaints during post-mortem by examining the appearance of the lungs, noting the weight of each, and testing whether a small piece of tissue floated in water in order to check the oxygen content (Ross, 1925). From his similar descriptions of the effects of lung disease on the body, however, it appears that Pilkington had trouble differentiating between the seemingly identical complaints of phthisis, tuberculosis and congestion. The weight of each healthy lung was considered to be 15–24 ounces, yet among patients reported to have died of ‘congestion of the lungs’, weights ranged from seven and six ounces in Caroline Belson’s right and left lungs, respectively, to 48 and 18½ ounces in Mechach Bew’s (OHA PMEB, Caroline Belson, 17 June 1886: 32–4; Meshach Bew, 21 Aug. 1886: 51–3; see also Ross, 1925: 226). Heavy lungs were also a sign of ‘inflammation’, as in the case of Sarah Godfrey, and of tuberculosis, as in the case of Elizabeth Edmunds, whose lungs both weighed over 34 ounces.⁵ In the case of Agnes Caless, however, who was diagnosed with phthisis, the lungs were found to be of normal weight (OHA PMEB, Agnes Sarah Caless, 28 Apr. 1886: 20–1). The appearance of the lungs was also often described in similar terms for different diseases. Lungs were engorged and deep red in colour in cases of congestion and pneumonia.⁶ This reflected a problem of definition in the wider medical community. Contemporary articles in The Lancet addressed this by arguing that the definition of lung disease, particularly ‘congestion of the lung’, was inaccurate (Beale, 1890; Wilks, 1890a, 1890b). By 1890, it was argued that the term had come to refer to ‘the privileged complaint of the upper and pay classes, whilst inflammation of the lungs has been degraded to the wards’ (Wilks, 1890a). Although it would therefore appear that all these lung conditions were the same, patients who were reported to have suffered ‘congestion’ may have been considered more upstanding members of society, while those who died of ‘phthisis’ or ‘inflammation’ were seen as members of the lower classes. As the Littlemore was a county pauper asylum, it would be expected that the lung conditions of the lower orders be ascribed more frequently than ‘congestion’, but this was not the case. Pilkington recorded congestion as the cause of death in 14 cases, but phthisis, tuberculosis and inflammation in only eight, two and one respectively. It was likely that he was using ‘congestion’ as an umbrella term and ascribing it cases of general lung disease where he could not be more certain of the diagnosis.

General Paralysis of the Insane

Of the 60 post-mortems recorded in the book, there were 11 cases of General Paralysis of the Insane (henceforth GPI). The condition was believed to have been suffered primarily by men in their prime, but of those reported at the Littlemore, five were male and six female (OHA PMEB; Williams, 1892; see also Davis, 2008; Wright et al., 2013). Symptoms typically included three stages of progressive cognitive and physical decline, usually resulting in death within three years of its onset as there was no known cure (Jelly, 1884; see also Davis, 2008; Wright et al., 2013).⁷ It was notoriously hard to diagnose, and its prevalence by the second half of the nineteenth century made it a fascination of alienists and general medical men alike (Handford, 1888; Wood, 1893b: 730). In her extensive examination of GPI in Scotland, Davis found that by the late nineteenth century ‘as many as twenty per cent of British male asylum admissions received this diagnosis’ (Davis, 2008: 15), and by 1902 the condition claimed 28% of all deaths at the Royal Edinburgh Asylum (Wright et al., 2013: 604). The cause of GPI was uncertain in this period, and understanding of the condition was ever developing. The link to syphilis had been suspected for decades, but not generally accepted as the primary cause until the late nineteenth century (Waddington et al., 2011: 368). Even then, the link was still disputed (Mortimer, 1889). This was often due to the decent types of men who came to suffer the condition and the unwanted sexual stigma associated with syphilis (Waddington et al., 2011). It was well known to be a ‘disease of civilisation and of modern times’, which attacked the ‘more intellectual members of the community’ in whom insanity was not inherent (Jelly, 1884: 217; Mercier, 1902: 164; Williams, 1892: 744). By the mid-1880s, sexual indulgence was considered to be a cause of GPI, along with overwork, excessive drinking and prolonged mental anxiety, but the term syphilis was often carefully avoided (Jelly, 1884). In his 1892 article ‘Wages of sin’, the medical superintendent Henry Williams acknowledged that syphilis was the chief cause of GPI, but could not bring himself to use the term as ‘it in itself [is] a synonym for immorality’ (Williams, 1892: 752).⁸ At the Littlemore, Pilkington was careful not to make mention of venereal disease in any of the post-mortem reports.

The range of mental symptoms associated with GPI made it notoriously hard to diagnose. Davis (2008: 112–13) has claimed that in some cases the diagnosis could not formally be given until ‘the distinct pathological changes in the brain’ were uncovered on post-mortem. Indeed, Mercier (1902: 184) stated that ‘there is no other malady in which the same combination of (pathological) changes is found’. These included a thick and heavy skull, thickened dura mater, and a shrunken brain. None of the Littlemore post-mortem GPI cases, however, share any specific combination of symptoms. This brings the diagnosis itself into question. Having known the patient’s case history, it is likely that Pilkington would have entered the examination with the predetermined cause of death in mind. In the case of the patient George Newbury, it has been possible to link his post-mortem report with his patient case records from the Littlemore. It would appear from his admission notes that Newbury presented classic early symptoms of GPI, which were strikingly similar to other contemporary accounts (Sutherland, 1885; Williams, 1892). Williams claimed that during the early stage of the condition, the patient will be intensely depressed, ‘his mind is made up of doubts, fears, and questionings’ (Williams, 1892: 750). Newbury was recalled as talking ‘of destroying himself, believes he is unfit to live, says he must die as he is consigned to the flames of hell’ (OHA MCBM, George Newbury, 15 May 1882: 63). He was reported to have been restless and excitable early on, with an ‘imbecile expression on face’, but later became thinner, more feeble, and eventually paralysed and unable to speak (OHA MCBM, Newbury, 15 May 1882: 63; 11 Aug. 1886: 212; 18 Aug. 1886: 246). One overlapping symptom in the post-mortem accounts of those diagnosed with GPI was bedsores. The frequent motor paralysis caused by late-stage GPI would have inevitably caused sores for many patients (Mercier, 1902). In many cases, the bedsores reported with ‘irregular shape’ may have even been syphilitic sores, which were found on male and female patients alike (OHA PMEB, Belson: 32; Aaron Thomas Arnold Soanes, 24 Nov. 1886: 78). Overall, while GPI was clearly difficult to diagnose in life, it would not appear to have been clarified by Pilkington at the post-mortem table. Nevertheless, the condition was deemed to be the cause of death in a significant proportion of cases. Perhaps its presumed prevalence by the 1880s made it a default diagnosis for Pilkington, regardless of the lack of physical signs on the body.

Dementia, epilepsy and mania

The next most common causes of death recorded in the PMEB were dementia, epilepsy and mania, respectively.⁹ These conditions have been grouped together here as, similar to GPI, there was no consensus among contemporaries on how these conditions showed themselves on the body post-mortem. For the most part, it was agreed that there were minimal signs which could be found after death (Ross, 1925)

Epilepsy was thought to be associated with insanity in a number of ways (Mercier, 1902). Epileptics were thought to be either permanently insane or temporarily, in connection with their fits (Mercier, 1902). Medical textbooks of the early twentieth century listed three types of epilepsy, but the diagnosis of the Littlemore patients would most likely have referred to the ‘psychical’ kind (Caille, 1907: 721; Wilcox, 1907: 802). This form of the disease was the rarest, but was typically characterized by mental disorders or violent acts (Caille, 1907; Wilcox, 1907). The ‘Facts indicating insanity’ included in the admission reports and case records of the 68-year-old patient Mary Cooper stated that the patient:

Gets out of bed in the night and attacks her fellow inmates dragging clothes of their beds. When restrained by the Nurse she is spiteful and attacks those who have the care of her, using very abusive language. She denies all this in the morning and is unsafe to be left for a moment. (OHA MCBF, Mary Cooper, 7 Feb. 1884: 148)

It was thought that cases of epilepsy had a predisposing hereditary cause, with around 30% of cases having shown a history of mental disease or epilepsy in the family (Wilcox, 1907: 802).

At the Littlemore, there did not appear to be any pattern in the condition of the body between the post-mortem findings of patients considered epileptics. For female patients thought to have died of the condition, reference was sometimes made to the genito-urinary organs, but not in every case. For example, the record of Mary Cooper found the uterus to be ‘atrophied’, yet the record of Jane Papal made no mention of her sexual organs, even though the 45-year-old was believed to have suffered ‘Epilepsy, mania with dementia’ which was seen to be caused chiefly by menopause (OHA MCBF, Mary Cooper, 7 Feb. 1884: 148; MCBF, Jane Papal, 18 Nov. 1886: 168–9). It is interesting that the genito-urinary organs of the female lunatics were not always inspected upon post-mortem at the Littlemore, given that the historiography places so much importance on them as a perceived factor of insanity in women during this period. Waddington (2011: 62) states that during the nineteenth century, the ‘female lifecycle was perceived to be fraught with dangers that could drive women insane’. According to Showalter (1980: 169), by the 1880s ‘psychiatric symptoms were interpreted according to a biological model of sex differences and associated with disorders of the uterus and the reproductive system’. Perhaps the lack of consistent reporting on an aspect of female insanity believed to be of particular interest during this period is further proof that Pilkington was not performing these examinations in order to make any contribution to wider medical knowledge. However, Pilkington did not ignore the genito-urinary organs, and in many of his reports he commented on the appearance of the uterus in particular. For example, in the case of Caroline Roberson, who was recorded to have died of mania, her uterus was found to present ‘the usual atrophied character of senile decay’ (OHA PMEB, Caroline Roberson, 24 July 1886: 43).

Mania was broadly defined as a ‘mental condition in which there is great emotional exaltation’ (Wood, 1893a: 567). The condition was sometimes thought to develop ‘with great suddenness’, as in the case of Reuben Yeates, who was admitted to the Littlemore after suffering the complaint for only a few days (OHA MCBM, Reuben Yeates, 30 June 1886: 108; see also Wood, 1893a: 567). In this case, the condition was believed to have been caused by cardiac disease (OHA MCBM, 1885–6: 109a). It was thought that the ‘maniacal stage’ was reached when the patient’s emotional excitement rose, causing delusions and hallucinations (Wood, 1893a: 568). Yeates believed his medicine ‘changed his skin and made it assume various colours’ (OHA MCBM, 1885–6: 108b). The post-mortems of patients diagnosed with mania also frequently mentioned bile in the liver or gall-bladder (e.g. OHA PMEB, Sarah Godfrey, 20 Dec. 1886: 85; Elizabeth Cantwell, 23 Dec. 1886: 88). Bile was also reported in a number of patients diagnosed with dementia, melancholia, epilepsy and GPI.¹⁰ The apparent importance of bile in the mad body reflects the continued influence of the humoral view of health and disease, which dominated medical thinking until scientific medicine began to replace it in the nineteenth century (Waddington, 2011). Bynum (2008: 10) defined humoral medicine as a ‘theory of temperaments, which provided a guide to human personality and susceptibility to disease’. It was believed that well-being was linked to the balance of the four humours (heat, cold, dryness, moistness) which were themselves each respectively linked to the four elements (air, fire, earth, water). These humours were also each associated with a bodily fluid, believed to reflect any imbalance in the body (blood, yellow bile, black bile, phlegm) (Bynum, 2008; Porter, 1999; Waddington, 2011). According to Porter (1999: 57, 271), it was believed since antiquity that black bile played a role in the appearance of melancholia, and that ‘mania resulted from bile boiling on the brain’. The sinuses of patients believed to have died of mania and melancholia were frequently reported to have been ‘filled with dark fluid blood’, which may have been believed to reflect such ‘boiling on the brain’ (OHA PMEB, Cantwell: 88–90; Godfrey: 85; Leah Baker, 20 Feb. 1887: 125). In the case of Jane Crawford, who was reported to have died of dementia and pneumonia, the sinuses were filled with ‘dark coloured blood clots’ and the gall bladder contained ‘two ounces of bile’ (OHA PMEB, Jane Crawford, 29 Mar. 1887: 132–3). Overall, although the dominance of bile had dwindled in the overall understanding of health and disease, in the 1880s Pilkington still appears to have associated it with the lunatic body. Humoral beliefs in the temperament of the body were evidently still underlying and influential in understanding insanity in the late nineteenth century.

Conclusion

The content of the PMEB has revealed that the examinations performed on the dead at the LCLA should most accurately be defined as dissections. These examinations were not called for by the coroner, and death notices specifying the cause of death were issued before the exams had taken place. If the findings of dissection suggested an alternative cause of death, the original notice was not amended. Pilkington was therefore not performing these exams in order to determine a cause of death. The Commissioners in Lunacy wanted as many lunatic cadavers as possible to be examined across the country, in order that the anatomical understanding of insanity was continually improved. The emotive language used by Pilkington to describe the appearance of certain body parts could arguably be a sign that his exams were fulfilling a level of personal curiosity. As he did not sell any of the LCLA bodies to medical science, it might be argued that he wanted to keep cadavers for his own personal education and use them to make an original and valuable contribution to medical and psychiatric knowledge. This would seem to be highly unlikely, however, as he did not publish any of the findings of his examinations, nor did he keep any specimens for later educational reference. The practice of recording examinations on the dead at the LCLA appears to have begun with the PMEB. Its creation by Pilkington in 1886 strongly suggests it was a speedy reaction to the Lunacy Acts Amendment Act of 1885, which called for asylums to protect themselves against accusations of malpractice and mistreatment. Therefore, the purpose of the dissections at the LCLA seems to have been a gesture to appease the demands of the Commissioners in Lunacy and simultaneously to protect the LCLA during a period of distrust against asylums and the psychiatric profession more widely.

Consent for these dissections was supposedly obtained from family members or friends when the patient was admitted to the LCLA. On the patient’s death, the notice was issued quickly but the examination was performed shortly afterwards, which gave no time for objections. This practice was legal under lunacy legislation, which the LCLA apparently followed, rather than coroners’ and anatomy laws. The appearance and reporting of this practice in the local courts and newspapers meant that the coroner, Mr Robinson, must have been aware of Pilkington’s routine examinations of the asylum dead. The simultaneous practice of asylum dissections and coroners’ post-mortems, both legal under different legislation, suggests that the men undertaking these overlapping and sometimes contradictory examinations must have known each other and have had some form of ‘Gentlemanly agreement’. However, the Simms case reported in the Jackson’s Oxford Journal (Anon., 1878) demonstrates that the practice of dissection at the Littlemore was often hasty and did not give the coroner time to determine whether an inquest and corresponding post-mortem were required. In this sense, Pilkington and the LCLA appear to have been conducting examinations on their deceased autonomously and without fear of reprimand from the wider legal or medical communities.

The PMEB represents a hugely underused source in the history of psychiatry and institutional care. It provides a unique and valuable insight into asylum death practice and into the appearance of the dead deemed insane. The contents reinforce our perception of the working-class patient base at county asylums, though it also highlights the larger presence of women being treated in such institutions than the current historiography suggests. The prevalence of lung complaints among the causes of death is not surprising, given that these patients probably lived and worked in conditions with poor air quality, as was common for the wider urban working-class of this period. The high number of patients diagnosed with GPI is also not surprising, as it was believed to have become widespread by the 1880s. It is unclear, however, whether these diagnoses represent a real increase in the number of people afflicted with this condition or an increase in the interest shown by contemporary alienists. The frequency with which bile was reported to have been found in the bodies of the insane reflects the continued underlying influence of humoral medical beliefs in contemporary understanding of madness. In a period when scientific knowledge of insanity was constantly changing, the long-held common beliefs of humoral medical tradition provided a recourse for modern science, which had yet to find madness in the brain. The focus placed on the brain in the PMEB reports was to be expected, given that pseudo-sciences including phrenology sought to pinpoint insanity in a period dominated by fears of degeneration of the national stock. It is clear from the PMEB, however, that Pilkington had no intention of contributing to these wider debates with any findings of insanity in the dead of the LCLA, which he kept wholly to himself throughout his appointment.