I have been absent from this blog for some time, but was reminded of it when I came across the following historical newspaper article in the Pall Mall Gazette (14 June 1870):
Only last week we called attention to Dr. Dickson’s solution of the problem of death by crushed ribs among lunatics in our asylums. The bones of paralytic patients are, he thinks, so soft that they must be broken occasionally during the endeavour made to quiet these patients. Another case of the kind has just occurred. A man named James Doran, formerly a solicitor’s clerk, had become insane, and was transferred from the Rochdale workhouse to Prestwich Asylum. He died the same day. The post-mortem examination revealed the fact that seven of his ribs were broken, but – and this is most significant – there was no corresponding exterior mark of violence. These fractures, therefore, were not caused by a fall, or by blows. We should be glad if any one could tell us how they could have been produced except by heavy quiet pressure, such, for instance, as a heavy man kneeling on the chest. The jury, of course, found that the poor man had died from natural causes, death being accelerated by injuries, but that there was no evidence to show how the last were inflicted. No one will be punished, and so another wretched lunatic is consigned to his grave, and the work of crushing ribs goes on gaily, and with amazing impunity.
It was such a sad story, hinting quite strongly that unnecessary force may have been used during restraint procedures, that I wanted to find out more about what happened.
So who was James Doran?
In 1861, James Doran is living at 12 Hopwood Place, Wardleworth, Rochdale aged 41 with his wife Mary (aged 21, from Weaverhouse, Cheshire) and sons Edward A (aged 3) and William P (aged 1/2 year or 6 months) [Census reference: Class: RG 9; Piece: 3043; Folio: 32; Page: 13; GSU roll: 543069]. His death was registered in Manchester registration district (of which Prestwich is part), and he is reported to be 52 years old. His young wife would have been around 31 years old.
James, a widower, married 17-year-old Mary Richardson on 12th Feb 1851 at St Chad’s, Rochdale. His father is listed as John Doran, currier (Full marriage records available at Ancestry.com as part of Manchester, England, Marriages and Banns collection).
James married his first wife Anne Waine on 26th November 1846, also at St Chad’s, Rochdale. She may be the Annie Doran who died in Rochdale in 1849.
James’s mother and siblings are also living in Wardleworth in 1851 (Address: 2 Hope Street). All were born in Rochdale. His family at the time consists of mother Jane (aged 58), brothers Edward (aged 28, hair dresser) and John (aged 11), and sisters Jane (aged 34; reeler of cotton) Catharine (aged 24, carder of cotton), Sarah Ann (aged 21, carder of cotton). Two of Jane’s grandchildren, William (aged 8 and Eliza aged 11 months) are also living with them [Census reference: Class: HO107; Piece: 2246; Folio: 174; Page: 7; GSU roll: 87266-87267]. John Doran (James’s father, aged 60, born in Ireland) is lodging separately at 2 Procter Court in 1851, possibly at his place of work? [Class: HO107; Piece: 2246; Folio: 193; Page: 47; GSU roll: 87266-87267]. The family are at 4 Portland Street in 1861 [Class: RG 9; Piece: 3043; Folio: 30; Page: 10; GSU roll: 543069]. Edward Doran is interviewed at the inquiry into James’s death (see newspaper article below).
James’s two sons: Edward Arthur and William Peel were both christened at St Chad’s, Rochdale, Lancashire on 3 Dec 1860 (Full baptism records available in Ancestry.com Manchester, England, Births and Baptisms collection). Sadly William Peel Doran seems to have died shortly after the 1861 census took place, towards the end of 1861. Edward Arthur appears to be living with his aunts Sarah Ann (and family) and Jane in 1871 (it is not clear where his mother Mary is). He later became a mechanic, married Mary Alice Howarth on 30th June 1877 at St Chad’s Rochdale, and had a number of children (see 1881 census). He died in 1893 aged just 38 years old.
A previous report of the inquest into James’s death ran in the Liverpool Daily Post on 13th June 1870. It gives some more details of James’s “lunatic” behaviour, as well as his medical treatment at Prestwich Lunatic Asylum.
MYSTERIOUS DEATH OF A LUNATIC.
An inquest was held at the Prestwich Lunatic Asylum on Friday, before Mr. Price, coroner, on the body of James Doran, a lunatic, whose death took place in the asylum on Tuesday.
Mr Watson, assistant medical officer at the asylum, stated that the deceased was admitted an inmate, under an order of the county magistrates, about half-past six o’clock on Tuesday. Witness saw him immediately after his arrival, and found him in an extremely prostate bodily condition. Upon making an examination he found several bruises on the body of the deceased, and some of his ribs were broken. There was also a recent bruise on the left temple. Witness ordered him to be put to bed, and to have stimulants administered to him. He was rambling and talking in an excited manner, and moving his arms to and fro. He was given in charge of an attendant, and about half-past eight o’clock the same evening it was reported that the man had died. Witness made a post-mortem examination of the body on the following evening, and found, on the left side, that the third, eighth and ninth ribs were broken; and on the right side, the fourth, fifths, eleventh and twelfth ribs were broken. There was no pleurisy or effusion in the chest, but the lungs were in the first stage of congestive pneumonis. There was also a disease of the heart and of the brain, the latter being in a generally softened state. Corresponding with the bruise on the left temple, witness found some blood effused over and amongst the fibres of the temporal muscle. The membrane covering the ribs was not ruptured in any instance, and there was no injury to the pleura, which accounted for the absence of inflammation. Witness attributed death to disease of the heart, lungs, and brain, accelerated by the fractures of the ribs. The removal of the deceased from Rochdale, and the motion of the cab in which he was brought to the asylum, would contribute to the causes producing death. The outward bruises on the body, with the exception of the one on the temple, were not of recent date, but it was difficult to fix a probable time when they, or the fractures of the ribs, were caused. The fractures did not correspond with the bruises in any one instance.
Edward Doran said he was a barber, residing in Rochdale. The deceased was his brother, and was an attorney’s clerk. He was 52 years of age, and had always been a temperate man. About two months ago he appeared to be weak in his mind, and a fortnight since he began to exhibit signs of insanity. On the Monday following he began to be violent in his conduct. Witness had never heard of any violence having been used towards him by others in consequence of his conduct. He continued in a violent state up to the 2nd instant, when he was removed to the Marland Workhouse at Rochdale. Witness never heard him complain of having been injured, nor did he see any marks upon him. He remained there from Thursday to Tuesday, when the relieving officer sent to ask witness to accompany the deceased from the workhouse to the Prestwich Asylum. Witness went to the workhouse, and observed several black marks upon his brother’s face, and upon asking the attendant how the marks came there, he replied that he did not know, but that sometimes the deceased beat his face with his hands. The governor said the same thing. On the way to the asylum the deceased had a paroxysm of insanity, and struck witness in the face. He also made several ineffectual attempts to strike witness, and shook his fist at him, but appeared too weak to carry out his intention.
William Whitworth said he was one of the relieving officers of the Rochdale union, and assisted to removed the deceased to the workhouse, and subsequently to the asylum. He corroborated the previous witness’s statement as to the deceased not meeting with any accident while on his way to to the asylum.
James Lawton said he was a surgeon, practising at Rochdale, and was medical-officer of the Marland Union Workhouse. The case of the deceased was first brought under his notice on Friday morning, the 3rd instant, when he saw him at the workhouse. He was in a very nervous and excited state. He again saw the deceased on Saturday, and found him in the same excited state as on the previous day. There were slight bruises on his temple, but nothing of any moment. He thought they were such as the deceased might have inflicted upon himself, but he noticed very little of his external appearance beyond seeing that the muscles of his face were distorted with shouting. On Monday witness again saw him, but found no change for the better had taken place. He was under partial restraint, sufficient to prevent him striking himself. Witness had no suspicion that the deceased was suffering from fractured ribs; he was so violent that it did not occur to him (witness) to examine him physically. His opinion, derived from the post-mortem appearances, was that the deceased had been suffering from fractured ribs several days before his death.
The Coroner.-Do you think it possible he might have received those injuries through the inexperience of the workhouse attendants? Might they not have been inflicted upon him inadvertently?
Witness.- I was not present when deceased was brought to the workhouse, but the master assures me that every care was taken in putting on the strait waistcoat.
By a Juror. – It is usual to examine a person who is brought to the workhouse, but I did not strip the deceased and subject him to a physical examination, because I thought it would have been injurious to him.
In answer to further questions, the witness said the ribs could not have been broken all at once, and that it was possible the injuries to two of the ribs were occasioned by a fall.
James Gent, master of the Rochdale workhouse at Marland, said that when the deceased was brought to the workhouse he was given into the charge of an inmate named Pilkington, who was assisted by another inmate. He was put into a bath by Pilkington, and afterwards placed in the epileptic ward, where there were several patients sleeping, and also a male pauper nurse. He was pretty quiet on Thursday night, but on Friday morning Pilkington reported that he was striking himself with his fist in his chest, and witness went and ascertained that this was the fact; ordered a strait waistcoat to be placed upon him, to prevent him injuring himself. The deceased was quiet, and there was no violence used in putting the strait waistcoat upon him.
The Coroner. – Can you suggest how he came to have his ribs broken, or to have the bruises on his face?
Witness. – I cannot. I spoke to the men who had charge of him to treat him kindly, and to use no unnecessary force. – In reply to further questions, the witness said it was usual to strip a patient coming into the workhouse and examine him before being put into the bath. In the present case they were short of a regular nurse; one had been appointed, but had not commenced his duties. That was the reason it was left to Pilkington and another inmate to look after the deceased.
William Pilkington said there were no bruises about deceased’s body when he was put into the bath, and he never complained of injury. He kept striking himself on the breast and side. He did not, however, get his ribs broken at the workhouse.
Edward Dunn, another inmate, who assisted the last witness gave evidence to the same effect and said every kindness was shown to the deceased while in the workhouse.
The Coroner, addressing the jury, said he would adjourn the inquiry if they thought proper, or there was any likelihood of getting additional evidence.
A Juror said it was his opinion that the deceased got injured at the workhouse, and he thought the authorities were very much to blame in not having examined the deceased both when he was brought in and when he was taken away, instead of leaving those duties to paupers. The medical man and the governor were paid servants, and yet they left their work to be done by the paupers. He remembered a similar case at Withington, but it was shuffled backward and forward, and nothing came of it.
The Coroner said he should be very glad to assist the jury in getting to the bottom of it, but the evidence was of a very contradictory kind. He had a case only ten days before, where a man died of fractured ribs of longer standing than in this case; but it was proved that he was of intemperate habits, and frequently got into rows. In fact he admitted that he had fallen down some steps when drunk,
At the request of a juryman, Mr. Watson was recalled, and asked whether he thought it possible that the deceased received the injuries without having been subjected to foul play.
Mr. Watson said he believed that the majority of injuries of this kind were inflicted without any intention of breaking a man’s ribs or killing him, and were simply the result of ignorance. The ribs could not all have been fractured at the same time.
The Coroner. – It only show the necessity of having experienced persons in cases of this kind, who will use all possible forbearance.
Mr. Doran was also recalled, and in reply to the coroner said he did not think he should be in a position to get any additional evidence.
The Coroner said unless the jury strongly suspected that the injuries to the deceased were caused by gross negligence, or such negligence as would amount to a criminal charge, against any person, they might be satisfied with returning an open verdict. If they thought the injuries had been caused in the workhouse, the matter ought not to be allowed to remain there, because another person might be subjected to the same treatment.
The jury returned a verdict to the effect that deceased’s death was the result of natural causes, accelerated by injuries, but how caused there was no evidence to show.
This is an intriguing and detailed report of what happened to James Doran. However, the question that leaped out at me is: where is James Doran’s voice in all of this? He is clearly an educated man, albeit poor, and able to read and write as he has been working as a solicitor’s clerk. His brother is a barber, another respectable trade. Was James physically unable to speak? Or was he unintelligible? There is no report of any conversation that he had with anybody over a series of days, although there is a reference to him “shouting”. I wonder whether beating his chest and side could have been an attempt to communicate that something was wrong internally? (pure speculation of course). I am also intrigued by the “softening” of the brain that is reported in the post-mortem: is this a result of neurological disease or injury? Could this have had an impact upon his behaviour? The other question that occurs to me is related to the use of the “strait waistcoat”, and whether improper use of a straitjacket can cause fractured ribs? This is alluded to in the original Pall Mall article (a theory about “soft” bones), but doesn’t seem to have been explored by the coroner in this case. I am also struck by the similarities of the circumstances of the case of Ah Ching, a Chinese gardener who died in Wellington Asylum, New Zealand in 1892.
The negative coverage in the media led to a governmental inquiry, as outlined in the following article from the Liverpool Courier and Commercial Advertiser (6th August 1870):
SUSPICIOUS DEATH OF A PAUPER LUNATIC. OFFICIAL INQUIRY.
Yesterday, Mr. A. Cain, Government inspector, held an inquiry at the Marland Workhouse, Rochdale, respecting the death of James Doran, a lawyer’s clerk. In June last Doran was taken to the workhouse as a lunatic, and on the following Tuesday he was removed to Prestwich Asylum, when it was discovered that seven of his ribs were broken, and he died a few hours after his arrival. An inquest was held, and the verdict returned was to the effect that death resulted from disease of the heart, accelerated by fractured ribs. An impression prevailed that Doran’s ribs had been broken in Marland Workhouse, and the official inquiry was looked forward to with interest. Mr. Jas. Gent, the master of Marland Workhouse, stated that he ordered Wm. Pilkington and Robert Putterworth to put the strait waistcoat upon deceased, as he was striking his chest, and it was done in his presence without any resistance. Dr. Lawton visited the deceased daily. Witness’s impression was that the deceased’s ribs were broken before he entered Marland Workhouse. Mr James Lawton and other witnesses were examined, after which Mr. Cain remarked that the whole of the evidence went to show that no violence had been used towards the deceased in the workhouse. However, he would lay the evidence before the Poor-law Board.
(Note: Cain’s name is given as R.B. Cane, Government Inspector in a similar article by the Leeds Mercury).
Ultimately, in this case there appears to have been no resolution, as no violence was found to have been used against James Doran. This conclusion is somewhat unsatisfactory, as there are still many unanswered questions, but I am ultimately heartened that people were asking questions about the treatment of “pauper lunatics”, and investigating reports of possible mistreatment and demonstrates the power of the media to bring attention to such cases.
Update: Apparently all was not well at Marland Workhouse, and the Master of the Workhouse had been previously fined for assaulting a pauper. An unfavourable report had been completed by the Lancet and published on 23rd April 1870, shortly before the death of James Doran in June that year. The Lancet followed the inquiry into his death and published an article in August calling the inquiry”curious and extremely unsatisfactory”.