Mortality in Victorian Asylums, ca. 1870-1910. The causes, processes and monitoring of lunatic death, with a focus on post-mortems

Abstract

This thesis examines causes of death from post-mortem records, an underused resource, in two asylums (the Royal Montrose Asylum and the Berkshire Asylum) in the period 1870-1905 to investigate their consistently high mortality. The Lunacy Commission recommended that asylum post-mortems should be carried out frequently to provide oversight of this mortality but also to encourage pathological research. This study examines the role of the asylum post-mortems in clarifying the causes of mortality while exploring their wider significance in elucidating discourses on theories of insanity. In a study of more than 600 post-mortem derived causes of death, it was fruitful to look at conditions such as mania, melancholia, dementia, imbecility and epilepsy separately. Death in insanity was more likely to occur in the early weeks of admission, often the first attack, but was not directly linked to overcrowding or malnutrition. Evidence is accrued to show that the severity of the mental illness, and neither suicide nor violence, was the key driver of premature death. Although rare, cases where violence against patients was evident provide a window into a cover up culture. About 60% of insane patients died from infections (40% from tuberculosis). The novel finding of atheroma in vessels, particularly those of the heart, was made in many of the insane, especially frequently in those who died with exhaustion, which accounted for 15% of deaths. Vascular disease was linked to pathology in the brain. The presence of vessel atheroma raises issues about the role of stress and adversity in these patients’ reduced longevity. This thesis contends that these routine post-mortems served limited clinical or academic purpose and played little part in reducing asylum violence. However, post-mortems helped to reduce opprobrium for staff in cases where patients had choked to death. Other positives included enhancing scientific benchwork and raising the prospects of pathological insights into insanity.