Abstract
This article examines alienist explanations for fracture among British asylum patients in the late nineteenth to early twentieth centuries. A series of deaths in asylums came to light in the 1870s which, in placing the blame for such incidents on asylum staff, called for a response from the psychiatric profession. This response drew upon other medical fields and employed novel pathological techniques to explain why fractures occurred among the insane, in many cases aligning bone fragility with particular forms of insanity (namely, General Paralysis of the Insane). Although such research aimed to provide a medical explanation for the ‘fracture death’, it also called into question the value of pathological research and the utility of quantitative measurement in understanding mental disease.
Introduction
January 1870 marked the beginning of one of the most heated debates in late-Victorian psychiatry, as a number of suspicious deaths in asylums came to public attention. The most contentious was that of Rees Price, an elderly patient admitted to Carmarthen Asylum who died shortly after admission. A post-mortem found eight broken ribs, and it was alleged that Price had received no proper examination on admission, or any special attention when he began to exhibit breathing difficulties. It soon transpired that in October 1869 Santa Nistri had died at Hanwell Asylum with eight broken ribs and a broken breastbone found at post-mortem; a few days after the Price scandal, William Wilson at Lancaster was reported to have twelve broken ribs when he died (Anon., 1870a; Anon., 1870b).
On 17 Jan. 1870, a letter appeared in the
The question of who was ultimately at fault for patients’ broken ribs did not yield a clear answer. At the heart of the issue was a much more philosophical problem about who was to blame for the deaths of those who were not like ‘normal’ people. Throughout the debate, the asylum patients’ inability to look after themselves was repeatedly emphasized, with many deaths said to have occurred as a result of falls or other accidents. The excitement, delusion or physical infirmity of the asylum patient was made to account for a wide range of events within the asylum walls, so that apparently inexplicable injuries could be rationalized by attributing them to the patient’s dysfunctional behaviour. Though an accident traditionally implied no human agency, changing understandings of the accident blurred the boundaries between accident and intentional act, so that ‘accidents’ coalesced to form a body of cases explained in the press as events neatly attributable to a corrupt asylum system. 2 Far from being apathetic about the fate of the asylum patient, there was a distinct thread of humanitarian concern running through many of these press accounts, suggesting the humanitarian narrative described by Laqueur. He identified ‘an extraordinary number of hitherto untold stories of human suffering’ (Laqueur, 1989: 190) disseminated in the nineteenth century (with particular focus on the poor) via Blue Books of parliamentary inquiries, which filtered into the mainstream press. This process of inquiry was ‘explicitly tied to sympathy for the plight of strangers’ based on the common experience of the body (p. 191). Newspaper articles certainly capitalized on the physical details of cases, describing how many ribs were broken and by what means injuries were believed to have been sustained. Ribs became, then, corporeal objects that provided a way into wider debates about the efficacy of the asylum system.
In many ways, the broken rib scandal was reminiscent of the concern for chloroform deaths (patients dying while under sedation), which had garnered significant public interest in the 1840s and 1850s. Like chloroform death, the broken rib phenomenon, though not particularly common, ‘was recurrent and afforded no clear causal explanation’, and – while a criticism of medical care was obvious – a degree of culpability was also placed on the patients themselves, with death partly explained as a consequence of their predisposition (Burney, 2000: 139). This concern for patient autonomy readily extended to asylum patients who were wholly dependent on staff for their day-to-day welfare. As one commentator noted, ‘a fracture which would pass unnoticed in a private family [became] most properly the subject of public judicial enquiry when it [occurred] in the inmate of a lunatic asylum’ (Ormerod, 1871: 576), suggesting that asylum staff bore responsibility for their patients much as a parent might for their children.
Many press features hinted that the news items reaching them were merely the tip of the iceberg: elsewhere ‘all [went] on merrily; lunatics’ ribs [got] broken somehow, or [broke] by themselves; the fact of death [was] notified to friends, to whom the news [came] as a relief [and] quiet funerals [took] place’ (Anon., 1882: 381). Official statistics suggested otherwise: the Blue Book of 1896 recorded 7,182 deaths in English and Welsh asylums, 11 of which were a result of fractures or dislocations (Briscoe, 1898: 1677). The
Although broken ribs and bones were reported in many asylums – both in Britain and elsewhere – the key examples that I use in this article come from the West Riding Pauper Lunatic Asylum in Wakefield. As will become clear, the West Riding Asylum is particularly relevant to the debate about asylum fractures by virtue of the experiments undertaken by its staff in the later nineteenth century. Opened in 1818, this Asylum played a key role in nineteenth-century psychiatry, particularly from the 1870s onwards. James (later Sir James) Crichton-Browne, Superintendent in 1866–76, was instrumental in pushing the asylum in a more self-consciously scientific direction, appointing a pathologist, setting up a laboratory, and editing six volumes of the
Identifying the problem: the fracture death and the vulnerable patient
Discussions of broken ribs centred upon the evidence offered by the body of the patient, usually at post-mortem or coroner’s inquest. This was often the first point at which such injuries became apparent or, as the
Suspicious deaths became the subjects of coroners’ inquests; after the 1836 Births and Deaths Registration Act, it became a legal requirement to report all deaths, and the 1862 Lunatics Amendment Act required all asylum deaths to be reported to both the local coroner and the Commissioners. At the West Riding it was standard practice for the coroner to hold an inquest, not only in cases of suspicious deaths, but for deaths occurring a few days after admission.
4
The coroner’s warrant books for the West Riding spanning 1834–79 contain 384 cases, 44 of which mention ‘fracture’ as a sole or ‘accelerating’ cause of death.
5
One of these cases, Henry D., predates the scandals of 1870 but highlights how the key elements of the broken-rib case were already present a few years earlier. Henry was admitted to the asylum on 24 April 1863 from the Wakefield Workhouse where he had been discharged after a short prison stay. On 27 May, a lengthy entry in the casebook recorded: This was a case of Dementia with excitement and also suffering from General Paralysis. He was in feeble bodily health and reduced in flesh … He was observed [at] admission to have slight
In this extract, the words printed in italics are underlined in blue pencil in the record, suggesting that the pertinent points of the case were highlighted after death when the case became of legal concern. The post-mortem found seven fractured ribs. The patient was free from the bruises described above, and the appearance of the ribs apparently indicated that the fractures ‘had occurred not less than 2 weeks before death but might have been of 6 or 8 weeks standing.’ 7 Henry D.’s case constituted a classic case of rib fracture: he was restless (pushing his bedstead around the room) and incurred fractures that were the possible result of his own actions (breaking through a glass door).
It is clear from examining Wakefield’s records that by no means all cases of fracture resulting in, or occurring close to the event of, death became the subject of coroner’s inquest, however. Thomas T., aged 69, was found to have three broken ribs at post-mortem, yet the coroner attributed his death to a combination of bronchitis, pleurisy and erysipelas of the arm. Explaining his decision, he said: ‘As to the fractured ribs it was evident they were not of quite recent date and it was thought probable that they had occurred by one or more falls, which could hardly be prevented.’
8
This tendency to dismiss some fractures as contributory causes of death according to their circumstances was also evident in the case of Widdop P., a 38-year-old man diagnosed with general paralysis who died 11 days after admission: A broken rib was found after death and an enquiry held accordingly. From the probable date of the fracture (it was but quite recent) and from the fact that previous to being brought to the Asylum, the patient had fallen headlong down stairs, it was decided by the Jury that the accident had occurred to the patient previous to admission, the Attendants being exonerated from all blame or suspicions.
9
Evidently the coroner, rather than judging deaths solely on the basis of physical evidence, might also address the circumstances surrounding death; this holistic view, however, was not always met with satisfaction.
10
In 1868 the Asylum and the coroner attracted criticism in the local press due to the verdict returned by two inquests in which fractures were present: death was ruled in both cases to be due to ‘Natural Causes’ and the fractures present deemed ‘unassociated’.
11
The
When the registration of cause of death began in 1838, accidents were typically grouped together with other ‘violent’ deaths, but Green (1997) argues that as the century progressed and birth and death statistics became more sophisticated, deaths involving violence (including accidents) began to be classified along lines of culpability and more thoroughly investigated. In the case of asylum deaths, the general consensus was that the onus lay with the attendant, who was responsible for the patient’s welfare at the time of his or her accident and had not exercised proper attention. As the perils of modern life intersected with naturalistic thinking, ‘people thought that accidents took place when someone who should have been able to control events did things wrong’ (Burnham, 2009: 221). Thus, stories abounded of accidents that had befallen patients when their attendants had momentarily left the room or turned their backs: a scalding in a bath, a tumble down some stairs, a laceration from a window pane.
Accidents are also not as random as their definition might suggest (Campbell R, 1997; Davidson and Townsend, 1982: 126–8). They tend to occur towards the lower end of the socio-economic scale and – just as occupational diseases or deficiency diseases such as rickets ‘had a strong tendency to social class specificity in their choice of victims’ (Bartrip, 2002: 2) – so too could the broken ribs of asylum patients be viewed as an ‘epidemic by instalment’ (p. 2) affecting a particular social group. It is understandable that the correlation of injury/asylum was explained by placing blame on asylum attendants, but the problem could also be seen from another perspective: that the insane were genuinely predisposed to fracture or incidents which put them at increased risk of sustaining injury.
‘A distinct pathological entity’? 14
As popular interest grew, the medical press witnessed a corresponding increase in articles detailing fractures in the insane, while works on bone disease frequently included short sections dedicated to the topic. 15 The discourse recalls that identified by Sammet (2007) on haematoma auris in early nineteenth-century Germany: asylum staff, dismissing the possibility that haematomas of the ear were caused by attendant violence, explained them as the result of an underlying condition in patients suffering ‘inflammatory irritation of the meninges’ (Sammet, 2007: 293). The diagnosis was visual, at first with the naked eye then via microscopical investigation. While Sammet (2007: 298) concludes that ‘[a]lienists’ obsessive exploration of an unimportant lesion showed their concern about their inability to ever become the real rulers’ of their institutions, the problem of broken ribs in the asylum differed from that of haematoma auris in one important respect: fractures were not trivial, but often proved fatal and propelled the asylum directly into the spotlight.
One condition predominated in these discussions of fracture among the asylum population: General Paralysis of the Insane (GPI). Now believed to refer to tertiary syphilis, GPI was a familiar sight to nineteenth-century superintendents, characterized by grandiose delusions and various reflex disturbances.
16
It was a fatal condition: many patients diagnosed with GPI died within a few months, sometimes weeks, of admission. W.H.O. Sankey (a Superintendent at Hanwell, then in private practice) had noticed that fractures found at post-mortem tended to be in those patients who were male and recent admissions. The extent of the fractures was beyond what would be expected as the result of a simple fall; nor, he surmised, could so many breaks occur as a result of attendants ‘kneeling’ on patients. Instead, Sankey attributed such injuries to the impaired reflexes and dulled sensations of GPI patients who ‘[threw] themselves about with reckless violence’ (Anon., 1870e: 138); this, he said, explained the preponderance of male cases (GPI was more often diagnosed in men) and recent admissions (admitted at the height of characteristic paralytic violence). Sankey highlighted the key elements of GPI that led to injury: impaired sensations, great excitement or violence, and muscular weakness leading to clumsiness (see also Brown and Rogers, 1870: 96).
17
In West Riding patient Thomas S., both a lack of reaction to injury and excitability were evident, his case having been assessed at admission as one of acute mania and suspected GPI.
18
His death was preceded by the discovery of several fractured ribs, attributed to an incident two days previously: … the patient … having been taken to a seat in the dayroom of his ward, suddenly got up ran down the gallery and kicking over a bucket which was in use fell headlong upon it. The patient did not seem hurt at the time and ate a good breakfast afterwards so that although the accident was reported by the attendant it did not attract special attention at the time.
19
The importance of GPI in Thomas S.’s death was clear in the coroner’s verdict: ‘accidentally falling over a slop pail in the gallery of no. 18 ward, and thereby fracturing his ribs and causing pleurisy – he being at the time in an advanced stage of general paralysis’. 20 The characteristic excitement of GPI led to Thomas’s accident, but the condition also complicated subsequent treatment as his diminished sensations allowed him to ‘[eat] a good breakfast afterwards’ and give no cause for concern. Lack of complaint from patients was a common theme: Walter M. ‘whilst at work … had a severe fall but said nothing about it[,] went about as usual and made no complaint of injury until, attention being attracted by his delicate appearance he was examined physically’. 21 At this point, fractures were found which Walter attributed to a blow while working, but which he dismissed as painless. In contrast to the general hospital patient, it was the asylum patient’s non-response to accidents that marked them out as especially problematic. The GPI patients also had a tendency to place themselves in dangerous situations: they held ‘very exalted notions of their own power and ability, and a strong propensity to order and direct every one else … combined with great muscular weakness, diminished sensibility to pain, and inability to protect themselves’ leading to quarrels with others where they were ‘at a disadvantage’ (Anon., 1870g: 254). Even left alone, their restlessness and lack of physical control might impact on their physical well-being, with falls out of bed often resulting in injury.
Not all cases of fracture could be traced back to an accident or violent incident, however, leading some to look to the asylum environment itself as a factor in bone disease that increased the tendency to fracture. ‘I do not think that asylum life [produces bone] disease’, wrote Scottish alienist William Carmichael M’Intosh, ‘but certainly I think it would aggravate the tendency’ (M’Intosh, 1862: 150). If patients spent their days sitting in wards or confined to bed, it was hardly surprising that their physical health would suffer. The poor state of many patients also militated against their recovery from relatively minor injuries. Commenting on the death of one patient after a leg fracture, Herbert Major noted: ‘In a younger and healthier subject than the patient was, the injury would not probably have been attended with any serious consequences but in the debilitated, unhealthy constitutional state in which he was … it brought about a fatal issue’. 22
The argument that environment could affect the fabric of the body, coupled with a desire to link mental disease to underlying somatic disorders, gave alienists reason for optimism. The discovery that weakened bones were linked to GPI would not only go some way towards absolving asylum staff of the charges made against them, but demonstrate the value of asylum science to the study of mental disease, and to medicine more generally. It was at post-mortem that alienists found some of the most striking evidence of bone disease in their patients, suggesting that the physical behaviour of the patient may not be the only explanation for fracture. George J. Hearder, Carmarthen Superintendent, found nine out of his 20 post-mortems revealed ribs in a ‘diseased state’ (Hearder, 1870: 566), mirroring the findings of investigators both inside and outside the asylum who graphically described the unusual appearance of the bones under study. They could be snapped between two fingers, were ‘soft and boggy’ (Mercer, 1874: 541), ‘like wet leather’ (M’Intosh, 1862: 146) or ‘sponge soaked in fat’ (Pedler, 1871: 165–6), and when cut exuded ‘a thick bloody fluid’. 23 Some described being able to tie bones in a knot at post-mortem due to their incredible flexibility (Macnamara, 1878: 222–3), and their anomalous appearance might be evident for years to come – remaining dark and rotten when preserved (Ormerod, 1871: 572).
These observations typically led to a post-mortem diagnosis of mollities ossium, or osteomalacia –an abnormal softening of the bone. Outside an asylum context, osteomalacia was most often seen in women and the elderly, manifested via symptoms of bone pain and a tendency to fracture easily; in extreme cases, the condition could lead to distortion of the limbs and torso. 24 The aetiology of the condition was at that time unclear. Some described it as the adult counterpart of rickets (Markoe, 1872). Others argued it was a distinct disease, involving muscle degeneration alongside skeletal abnormalities (Jones T, 1887). There was general agreement that the condition was prevalent in women, usually those who had had children. Walsh, studying four female cases at Wakefield Asylum in 1891, singled out for particular comment one woman who had the condition despite never having borne children; the presence of the disease in her case was even more extraordinary because she was the only one of the four still living (Walsh, 1891: 170). The condition’s presence in the elderly, another group in which it seemed especially common, was explained as one of the natural processes accompanying senility, and a consequence of unhygienic surroundings and insufficient diet.
That mollities ossium might be seen in a range of demographic groups thus opened up the possibility of viewing the condition as coincident with a generally deficient bodily system. Indeed, Markoe’s
At Wakefield in 1871, it was reported that four women had died of mollities ossium. 25 It was not uncommon to cite mollities ossium as a cause of death: it was understood as a progressive condition in which ‘nothing [could] be accomplished but the palliation of suffering’ (Markoe, 1872: 85). Orthopaedic specialists such as J. Jackson Clarke (1899: 34) dismissed the condition as one worthy of their investigation for precisely this reason as it offered little scope for medical intervention. Many alienists, however, could ill afford to ignore the issue of fracture among their patients, and post-mortem evidence offered an ideal illustration of the atypical pathology of the insane. It was not enough, however, simply to reiterate examples from personal experience to prove a tendency to bone breakage; indeed, the retrospective tone of many examples might merely fuel public suspicion. If alienists were to demonstrate conclusively that fragile bones were a common phenomenon in insanity, they would have to offer some concrete proof.
Quantifying bone fragility
When investigating fracture, it was the strength of the bone – rather than its appearance – that had most immediate relevance. Clouston had tested the bearing weight of the ribs of the insane in 1870 (Anon., 1871: 634), and by the 1880s Joseph Wiglesworth offered perhaps the most complete account of the issue. The entry ‘Bone degeneration in the insane’ in Tuke’s
Although Pedler had tested the breaking strain of ribs at Wakefield for his article in the
Why did Mercier take this step in the early 1890s when, as Tuke’s
Bearing in mind the purposes of post-mortem examination, what did investigations into breaking strain find? Campbell’s first paper was confident in identifying an average breaking strain of 44.8 lbs convex and 44.4 lbs concave in his male GPI subjects compared with 62 lbs and 65 lbs, respectively, in a healthy adult male (Campbell AW, 1895a: 256). His second paper on the subject, published only a few months later, was more hesitant and 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’ (Campbell AW, 1895b: 776). In this larger sample of 58 Rainhill patients and 50 Royal Southern Hospital patients, Campbell found very little difference between the breaking strain of the male asylum patient (41 lbs convex, 42 lbs concave) and that of the male general hospital patient (43 lbs convex, 43 lbs concave). He theorized that wasting diseases had greater influence on bone structure than mental afflictions, though of course GPI had a place on both sides of the argument. Campbell (1895b) was also forced to admit the existence of anomalies, making any concrete conclusions difficult: for example, two sane female patients from the general hospital had exhibited a breaking strain as low as five pounds.
The inconclusive nature of Campbell’s results did not, however, make the measurement of breaking strain entirely redundant. Mercier reported that, apart from Campbell, he had received no reply from any of the asylums who received his instrument, with the exception of William Lloyd Andriezen at Wakefield (Campbell AW, 1895a: 272). Andriezen had joined Wakefield Asylum’s staff as a medical officer in 1893 at the young age of 26.
26
Discussing Campbell’s first paper, Andriezen reported that he had used Mercier’s instrument in 122 Wakefield post-mortems (Campbell AW, 1895a: 273). An examination of the asylum’s post-mortem reports shows that breaking strain was systematically recorded from 30 September 1895. At the beginning of that month, pre-printed certificates appeared with spaces for the name, date of death, etc., and also contained a pointed reminder of the details to be included in the post-mortem record: ‘The following particulars are Statutory:- Condition – External Appearances – Bedsores – Head – Thorax – Describe
Although breaking strain was being recorded on a regular basis by Andriezen (and other medical officers), he never published the findings of the tests he alluded to during the discussion of Campbell’s paper, but Francis Simpson rectified this lack of data in his book,
By this time, the GPI/fragile bone relationship seemed to be in some doubt as a result of pathological examination. If bone fragility was a consequence of ageing rather than mental disease, alienist claims for expertise became much less relevant. Despite concern for fractures in coroner’s inquests and physical examinations, they were unable to suggest much beyond taking special care of ‘at risk’ patients. Other technical innovations in the alienist field had, like Mercier’s instrument, arisen out of concerns for the mistreatment of patients; Sammet (2006) has examined the development of rectal feeding as an alternative to oral force-feeding in Germany, for example. Technologies like rectal feeding had clear beneficial effect as the emaciated patient grew in strength. Pathological technologies, however, were of no practical benefit to the deceased patient whose body they acted upon: to many commentators investigations into breaking strain merely added insult to literal injury.
The skill of the individuals conducting such tests also came under fire, with general practitioners criticizing the supposedly amateur post-mortems in asylums. Pathology did not easily lend itself to professionalization when a pathologist’s tools might consist of ‘ham knives’ and ‘butcher’s saws’ (Burney, 2000: 120), and there was a tendency to view the asylum pathologist – like the asylum attendant – as under-qualified for his position (one can imagine the popular response to a doctor conducting experiments with a ‘concrete testing machine’). Bone specialist Charles Macnamara, though willing to accept the existence of an inherent condition causing fragility, was doubtful of the value of breaking strain tests, saying they were ‘hardly sufficient to convince you that the ribs of insane patients [were] at times diseased to such an extent as to render them extremely brittle’ (Macnamara, 1878: 230). He questioned the skill of the asylum pathologist in view of the fact that his own experiments had found no such pathological changes, and argued that such investigations should only be undertaken by those pathologists with special knowledge of the osseous system.
Despite sceptical reactions to breaking strain experiments, their findings did feed into practical changes. These brought the debate full circle, once again giving asylum attendants the responsibility for preventing injury. While the duties of the attendant were not clearly defined in the early nineteenth century, the second half of the century saw a concerted effort to mould attendants into an efficient and effective workforce, dedicated to the growing field of psychiatry (Nolan, 1993). In 1890 the Medico-Psychological Association (MPA) adopted the … very many of the inmates of asylums are advanced in years, and the bones of old people are easily broken. It must also be remembered that the bones of some patients, and especially of those suffering from general paralysis become unusually brittle … and a knock or a fall which would be of no consequence whatever to a young person in ordinary health, may readily break some of the bones of such patients, and produce very serious injuries.
The MPA’s
Assessing the fragile bone theory
By the early twentieth century, Wakefield Asylum’s post-mortem records displayed a distinct lack of concern for the breaking strain of patient’s bones. Despite the form providing a pre-printed line for ‘Ribs’, there was no meticulous charting of breaking strain; instead, vague statements were used such as ‘Rather Soft’ and ‘Softish’. 29 That the post-mortem records were kept in this fashion suggests that breaking strain was considered less useful as a pathological fact, but also raises the possibility that a normal standard of rib strength was generally agreed upon and needed no detailed elaboration (indeed, one record noted ‘Ribs rather softer than normal’ 30 ).
At the same time, William Maule Smith presented ‘On the nature of fragilitas ossium in the insane’ at the annual meeting of the British Medical Association, describing the results of his analysis of 200 post-mortems at Wakefield (Smith WM, 1903). He had not used Mercier’s instrument, preferring to rely on tacit knowledge: his ‘conclusions rested on the ease with which fracture was produced by digital compression’ (Smith, 1903: 824). His findings confirmed much of what Simpson had demonstrated, casting doubt on the idea that bone fragility was ‘a marked pathological condition in … general paralysis’. Discussing Smith’s paper, and his later lantern-slide demonstration of microscopic specimens (see Anon., 1904), familiar criticisms were voiced. Mercier noted, no doubt with a hint of mischief, that Smith’s observations on breaking bones with a finger ‘scarcely carried to an outsider the same conviction that could be produced by a numerical comparison’ (Smith, 1903: 827), while others cautioned against placing too much faith in pathological observations (Anon., 1904: 189).
As well as technical quibbles, the precise motivation for experiments into breaking strain was frequently unclear. Many articles gave the sense that individuals were explaining any doubtful incidents in their institutions before they were brought to light by a sensationalistic press. Such confessions, however, did not overcome the gulf that existed between alienism and medicine ‘proper’, and the public. Conflicting professional knowledge was often evident in court cases investigating fracture deaths; Joseph Workman (Superintendent of Canada’s Toronto asylum) was critical of a case in which it had been argued that multiple ribs could not possibly be broken without some pain, but in which no testimony as to the diminished sensations common to general paralysis had been heard (Lindsay, 1870: 419). While the insanity defence might absolve an individual of responsibility, the insanity-as-pathology defence at the heart of the broken rib debate rarely served to exonerate asylum officials from blame.
Yet the fragile-boned asylum patient was clearly an appealing explanatory model. Broken ribs became something of a self-fulfilling prophecy: Ormerod (1871: 571) noted that ‘the more attention has been called to [them], the more frequent does the occurrence seem to become’, suggesting that to some degree broken ribs fulfilled what Kanaan and Wessely (2010: 68) have called a ‘diagnostic need’. In the case of asylum fractures, a diagnostic need could certainly be deduced in the face of public scrutiny, but the influence of a drive towards pathological research must also be considered. Fractures may have thrown the alienist profession into disrepute but they could also, as the subject of detailed investigation, furnish new knowledge about mental disease and speak directly to alienist attempts to find a physical basis for patients’ conditions. The idea that the insane were peculiarly prone to bone disease was one that fitted logically alongside wider theories about both disease susceptibility and the general health of the asylum patient.
However, the response to the theory complicates the conclusion of Burney (2000: 164) that (in the case of the anaesthetic death) ‘[p]ost mortem accounts of preexistent [
Although short-lived, the theory of bone fragility in the insane mirrors the turn-of-the-century concept of accident proneness described by Burnham (2008, 2009). He argues that, around 1900, a group emerged in occupational health discourse who ‘suffered injuries and caused damage’ on a greater scale than the majority of workers (Burnham, 2009: 19). These were people who, through no calculated effort of their own, were apt either to endanger their own safety at work or jeopardize that of others. Like the broken rib phenomenon, accident proneness raised questions of how to ‘deal with [people] who [showed] a pattern of inadvertent but sometimes dangerous destructiveness’ (Burnham, 2009: 5) and could not be held accountable for their actions. The accident prone individual and the fragile-boned insane patient were both conceptualized as ‘natural objects’ (Burnham, 2009: 221; Smith, 1981: 161) – incapable of change and only able to be saved from themselves by external intervention, whether that be safety railings around machinery for the former, the use of padded rooms for the latter, or protective clothing for both.
Despite attempts at medicalization, the broken rib theory – like accident proneness – gradually disappeared as an explanatory paradigm. While doctors and pathologists investigating bone fragility had strived to elaborate a discourse of mental disease in which responsibility was absent, their findings did not change the basic fact that the asylum patient remained an individual in need of special care. Whether fractures were the result of violence or inherent weakness, the key figure remained the attendant whose responsibilities were unchanged by the suggestion that some patients were especially liable to fracture. By pathologizing the asylum accident and drawing attention to the body of the patient, the affair inadvertently accorded the body of the patient a peculiar authority: within the dramas played out in the pages of the
Footnotes
Acknowledgements
I am grateful to the Wellcome Trust (grant number 092991/Z/10/Z) for funding the PhD studentship from which this research is derived. I would like to thank Rhodri Hayward and Åsa Jansson for their comments on an earlier draft of this article, and Richard Noll for his enthusiastic encouragement.