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Bioarchaeological Analysis of Disability and Caregiving from a Nineteenth-Century Institution in Central Kentucky.

While the emergence and proliferation of mental-health institutions in North America during the nineteenth century is well documented, our knowledge of the conditions and daily lives of those they served is mostly limited to existing hospital and government records written by administrators and legislative officials (Grob 1994; R. F. White 1984). These documents often provide a general overview of the building facilities and operations, as well as routine practices of care and the philosophies guiding them; however, they offer very little information on specific cases or individualized therapies. Since the diagnoses and treatment plans are variable within the population of any institution, it is difficult to piece together what day-to-day life was like for individuals, especially in the absence of patient records. Bioarchaeological analyses can provide an avenue for exploring lived experiences of persons receiving care in this type of hospital, as well as contribute to understandings of how health-care practices are shaped in specific cultural and historical contexts (Phillips 2016; Roberts 2011; Tilley 2015; Tilley and Schrenk 2016).

The current case offers a unique opportunity to examine one patient's experience of disability at a mid-nineteenth-century mental-health-care facility (Eastern State Hospital) in central Kentucky in the United States. While most causes of mental illness do not leave evidence in the bones, the individual presents bilateral limb length asymmetry and skeletal atrophy suggesting neurogenic paralysis, which is often associated with a level of cognitive impairment requiring a corresponding level of support. The differential diagnosis of pathological conditions and subsequent bioarchaeology of care analysis presented below offer insight into her or his experience of disability and what the care she or he received at the hospital likely comprised.

Although the inference of disability and caregiving in the past has long been considered by some to be beyond the scope of archaeological and bioarchaeological research (e.g., DeGusta 2002; Dettwyler 1991), the bioarchaeology of care introduced by Tilley and Oxenham (2011) provides a theoretically and methodologically robust framework for systematically investigating the relationships between biological and sociocultural dimensions of disability and the provision of care in skeletal remains (Tilley 2015; Tilley and Cameron 2014). This approach is used to assess an individual's physical impairments within a specific cultural context, which in this case is an institutional setting. Since the individual was a resident in a hospital, it can be assumed that some level of care (ranging from direct support to accommodation of difference) was provided. Through careful consideration of the possible functional limitations arising from the individual's pathological conditions and the care practices available, a model of care is constructed. Applying the bioarchaeology of care approach in institutional contexts presents unique challenges (Critcher 2016; Phillips 2016; Roberts 2016; Wesp 2016). While records may be available about generalized methods of care, we often do not know how long an individual was a patient, and therefore it is not possible to determine whether past illnesses or injuries (and any care required) occurred prior to admittance. This is especially true for progressive disorders where the level of care required changes over time.

Context of Care

Eastern State Hospital (ESH) opened in 1824 as the state-sponsored Lunatic Asylum of Kentucky and remains the second-oldest continuously operating mental-health hospital in the United States. Due to planned redevelopment of the land, a portion of the hospital cemetery was excavated by the Kentucky Archaeological Survey in 2005 and 2011. A total of 186 individuals were identified from both mass and single interments. Following bioarchaeological analysis at the University of Kentucky William S. Webb Museum of Anthropology, the remains were reinterred at the hospital in 2012. Temporally diagnostic artifacts and archival research suggest that the portion of the cemetery uncovered was in use between 1839 and 1861 (Pollack and Worne 2014). Located in the city of Lexington, ESH served the state of Kentucky as well as the surrounding region. The resident population ranged from approximately 136 to 270 patients (EKLA 1840, 1849). Individuals of all ages were admitted to the hospital, with the length of residence ranging from days to decades. Employees responsible for patient care generally included the superintendent, a matron and her assistant, several attendants (roughly one for every 14-16 patients), a resident physician, and consulting physicians from a local medical college (EKLA 1840, 1849, 1859:22). Patients admitted to the hospital usually suffered from cognitive impairment, psychological disorders, or epilepsy. For many, ESH was a last resort, in part because of the negative public perception of such institutions, but also because the state of Kentucky provided relatives with stipends for caring for dependents at home (Brown 1998; Sunley 1939; R. F. White 1984). While most of the residents were subsidized by the state, some came from wealthy families who could pay for preferential treatment (EKLA 1844:625, 629; R. F. White 1984).

Throughout the early to mid-1800s, the hospital employed the treatments promoted by Benjamin Rush, an influential and controversial physician during the late eighteenth and early nineteenth centuries (North 2000; R. F. White 1984). Rush's treatment, known as "heroic medicine," involved depletion therapy (bloodletting and purging of the stomach and bowels) as well as cold and hot baths (used both as therapy and positive punishment). Confinement, sedation, and the use of physical restraints were considered a necessary part of patient management. Medication commonly prescribed at the time for psychological or behavioral issues, epilepsy, and other ailments included calomel (mercurous chloride, which often resulted in mercury poisoning), tartar emetics, opiates (laudanum or morphine), rubefacients, castor, mugwort, and absinthe (Joinson 2012; North 2000; Okoh-Esene et al. 2013; R. F. White 1984).

By the early 1840s, ESH incorporated many of the principles and practices of moral therapy (EKLA 1843; R. F. White 1984). Considered a more humane approach to care (cf. Foucault 2006), moral therapy sought to heal the mind as well as the body. Patients were expected to develop self-control and follow a strict daily regimen, which included regular physical exercise, fresh air, healthy diet, plenty of sleep, and maintaining personal hygiene (Grob 1994; R. F. White 1984; Yanni 2007). Residents were encouraged to take strolls around the grounds and were provided with an extensive library as well as indoor and outdoor games (EKLA 1844, 1859; R. F. White 1984). Patients were tasked with chores or labor as part of the hospital's therapeutic work program, such as manual labor related to construction and maintenance projects, gardening, and farming for men, while women were responsible for domestic activities such as washing, sewing, and ironing. ESH abandoned the aggressive use of restraints (such as chains and straitjackets) during this time. The use of cold-water baths also replaced many forms of corporal punishment.

Dorothea Dix, a prominent activist and advocate for institutional reform, visited ESH in 1846. While she found the staff competent, Dix described several problems with the hospital's living conditions, including inadequate bathing/washing facilities, insufficient heating (which reportedly resulted in frostbite and death during winter months), and the lack of separate quarters for individuals with contagious diseases (Dix 1846; EKLA 1847, 1853, 1857; R. F. White 1984).

Bioarchaeological analyses indicate that individuals interred in the ESH cemetery suffered from illnesses typical among pre-antibiotic nineteenth-century societies when poor sanitation, malnutrition, and infectious disease were common (Worne et al. 2014). Mortality rates for the hospital at the time were particularly high (38% in 1843 compared to 9-10% at institutions in the Northeast) (Joinson 2012; R. F. White 1984). Diseases commonly reported for the region at the time include cholera, dysentery, typhoid fever, tuberculosis, syphilis, scarlet fever, and pneumonia (U.S. Census Bureau 1860; R. F. White 1984). Outbreaks of cholera in 1849 and 1855 had the most devastating effect on death rates at ESH, likely contributing to the mass interments uncovered at the cemetery (EKLA 1849, 1855). Mortality greatly improved after it was discovered in 1856 that sewage had been contaminating drinking water, probably causing the chronic diarrhea that had plagued hospital patients for years (EKLA 1857).

Paleopathology of Burial 34

Burial 34 (B34) comprises the relatively complete skeleton of a late teen or early young adult (15-19 years old) (Fig. 1). Although the skeletal material was generally well preserved, several of the bones were fragmentary, with many of the small elements of the hands, feet, ribs, and vertebrae affected by taphonomic damage. The individual was buried in a hexagonal-shaped coffin in a single interment in the extended, supine position (Pollack and Worne 2014). One Prosser (or porcelain) button was located near the cervical vertebrae (possibly from a pull-over shirt or shift), and five four-hole bone buttons were found in the pelvic region (potentially closures for pants or a skirt). It is not possible to determine exactly when or for how long B34 was a resident, as individual patient records are not available from this time. However, archaeologists estimate that the individual was interred toward the latter half of the cemetery use (David Pollack, personal communication 2017).

Age estimation was based on dental development as well as epiphyseal fusion (right side only, due to pathological conditions observed on the left limb bones discussed below) (Buikstra and Ubelaker 1994; Moorees et al. 1963; Scheuer and Black 2000; Ubelaker 1989). Given the possibility that this individual suffered from a neuromuscular disorder, it should be noted that aging methods based on epiphyseal fusion and dental analyses have been found to provide inaccurate and inconsistent age estimations in individuals with cerebral palsy (Henderson et al. 2005; Ilikkan and Yalcin 2001; Lawrence 2013; Megyesi et al. 2009). Standard morphological characteristics of the crania and os coxae were used to estimate biological sex for the ESH skeletal sample (Buikstra and Ubelaker 1994); however, due to the ambiguous results, young age, and shape asymmetry present in the pelvis, sex was considered indeterminate for this individual.

The most notable pathological conditions observed in the skeleton of Burial 34 were the bilateral size asymmetries in the long bones of the arms and legs, the hands, and the patellae. The left humerus, ulna, radius, femur, tibia, and fibula all appear shorter and atrophic compared to those on the right (see Table 1 and Figs. 2 and 3). Fragmentation prevented measurement of both right and left long bone lengths for all but the humeri, which differed in length by 18 mm. Epiphyseal closure in the left proximal humerus and femur are more advanced than those on the right, suggesting premature growth cessation in the affected limbs. Although the left limb bones are generally more gracile than their counterparts, the crest of the left greater tubercle in the area of insertion for the pectoralis major (T. D. White et al. 2012) is prominent, thin, and sharp (possibly resulting from muscle contracture). Similar osseous changes to the distal left humerus and both proximal ulnae are visible in the areas of origin and insertion for the brachialis muscle.

While the os coxae do not appear to differ in size, the left greater sciatic notch is wider and more angular than the right. This shape asymmetry could have resulted from unbalanced hip muscles and/or altered gait during growth and development (Sawyer 2013). There is a small, incomplete, healing avulsion fracture of the posterosuperior margin of the left acetabulum (Fig. 4), possibly due to a tear in the labrum and/or subluxation/dislocation of the hip (Galloway 2014; Groh and Herrera 2009; Letournel 1980). The fracture line is still clearly visible; however, the edges are rounded with no evidence of woven bone deposition present, suggesting that the injury occurred between weeks to months prior to death (Lovell 1997; Maples 1986). Arthritic changes are visible on the left femoral head, including subchondral porosity and lipping along the posteroinferior margin of the articular surface.

The left patella has what appears to be a short antemortem transverse fracture line (approximately 4 mm in length) with smooth, rounded edges extending laterally from the medial border just superior to the distal pole of the bone (Fig. 5). This could be an incomplete (or partially fused) accessory ossification center (bipartite patella). Bipartition located in the inferior portion of the bone is rare (Saupe 1943) and is thought to be the result of avulsion of the distal pole (Sinding-Larsen-Johansson disease) associated with increased tension of the patellar tendon during adolescence (Ogden 1984; Ogden et al. 1982; Resnick and Niwayama 1981). The right and left tibial tuberosities are both prominent with the apophyses visibly separated from the underlying diaphysis on the inferior margins. This could be caused by avulsion of the tibial tuberosities (Osgood Schlatter disease) resulting from biomechanical stress placed on the patellar tendon during adolescence, similar to the injury described above for the left patella (Resnick and Niwayama 1981).

Other pathological conditions noted include a small squatting facet on the distal right tibia (Capasso et al. 1998; Trinkaus 1975), Schmorl's nodes on four lower thoracic and one lumbar vertebrae, inactive porosity on the orbital roofs consistent with cribra orbitalia (Ortner 2003), and mild diffuse woven bone deposition (periostitis) on the lateral aspect of the right tibia and medial aspect of the right fibula that was active at the time of death. Dental attrition is generally mild when present; however, slight para-functional wear patterns and considerable chipping (possibly due to bruxism) are visible on the occlusal surfaces of the anterior and right posterior teeth (Pollack and Worne 2014).

Differential Diagnosis

Some bilateral asymmetry in limb bone dimensions is normal (Auerbach and Ruff 2006); however, the markedly shorter left long bones and atrophic diaphyses suggest that this individual suffered from an underlying pathological condition with a childhood onset. Possible conditions considered in the following differential diagnosis include traumatic injury and neuromuscular disorders such as Duchenne muscular dystrophy, paralytic poliomyelitis, and cerebral palsy. Conditions that only manifest in adults, typically affect both sides of the body, and/or involve diagnostic skeletal changes absent in the current case were excluded from the discussion below (e.g., metabolic disorders, osteomyelitis, tuberculosis, arthropathies, juvenile dermatomyositis, spinal cord injuries, etc.).

Traumatic injury

Traumatic injury (e.g., fracture, dislocation) could result in growth cessation and musculoskeletal atrophy due to prolonged immobilization or direct insult to the physes (Peterson 2012). However, the widespread distribution of affected elements throughout both the upper and lower left limbs is unlikely to have all resulted from trauma. Furthermore, there is no evidence of past injury (e.g., callus formation, misalignment or angulation, infection, etc.) in any of the involved limb bones (Galloway et al. 2014; Lovell 1997).

Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD), an X-linked recessive neuromuscular disorder affecting males, is characterized by symmetrical, progressive weakness beginning in the proximal muscle groups of the legs between ages 3-5 years and in the arms during the mid- to late teens (see Table 2) (Emery 1991, 2002; Karol 2014b; G. H. Thompson and Berenson 2006; Warner and Sawyer 2013). Patients usually experience a complete loss of ambulation by age 12 and death by late adolescence or early twenties. Approximately 5-10% of female carriers of DMD show mild symptoms of the disorder, with onset occurring at any age (Hoogerwaard et al. 1999; Juan-Mateu et al. 2012; Song et al. 2011). Although muscular impairment in manifesting female carriers is generally asymmetrical, the distribution is not usually confined to only one side of the body. Given B34's age, ipsilateral involvement of both upper and lower limb bones, and the lack of evidence for complete paralysis, DMD and the more rare manifesting female carrier disorder are not likely diagnoses. The differential diagnosis is thus narrowed to paralytic poliomyelitis and cerebral palsy (see Table 2).

Paralytic poliomyelitis

Poliomyelitis is a neurotropic viral infection of the genus Enterovirus most often spread through fecal-oral transmission (Herring 2014; Modlin 2010). The polio-virus initially infects the respiratory or gastrointestinal tracts, potentially invading the central nervous tissue. The principal cause of debility is muscle weakness or paralysis due to destruction of lower motor neurons. When present, paralysis is characteristically flaccid, asymmetrical, and patchy in its distribution and tends to involve more proximal muscle groups of the limbs, with muscles of the legs more often affected than those in the arms (Chow et al. 2010; Modlin 2010; Sharrard 1955).

Multiple polio epidemics were reported from regions throughout North America, including Kentucky, by the early 1900s, although possible small outbreaks occurred as early as 1841 (Oshinsky 2005; Trevelyan et al. 2005). Relatively few bioarchaeological examples of polio have been documented, especially in the New World; however, a probable case has been identified in an individual from a mid- to late-nineteenth-century cemetery in southwest Mississippi in the United States (A. R. Thompson 2014).

Cerebral palsy

Cerebral palsy (CP) describes a number of disorders involving injury or insult to the developing brain (anytime between conception and 2-3 years of age) resulting in impaired motor function (Karol 2014a; Nelson 2008; Rosenbaum et al. 2007; Sawyer 2013). While the damage to the brain is non-progressive and permanent, the type and severity of the clinical manifestations can change or progress over time. The distribution of B34's affected elements most closely resembles the hemiplegic type of spastic CP, which involves the upper and lower limbs on one side of the body. Spasticity in CP often results in simultaneous contraction of normally antagonistic muscles, resulting in muscle fatigue, loss of coordination, diminished balance, and altered gait (Karol 2014a; Sawyer 2013). Hemiplegic CP patients frequently present other associated conditions beyond motor impairment stemming directly or indirectly from the original brain injury (see Table 3) (Koman et al. 2004; Sawyer 2013; Uvebrandt 1988).

Paralytic poliomyelitis versus hemiplegic cerebral palsy

Neither paralytic poliomyelitis nor hemiplegic cerebral palsy can be definitively excluded as possible diagnoses based on the osteological analysis alone, as both conditions could explain most of the skeletal manifestations observed in B34 (see Table 2). Bioarchaeological evidence for both polio and CP most frequently consists of atrophy and/or shortening of one or more long bones as well as other osseous changes such as femoral neck anteversion, hip dysplasia, scoliosis, and skeletal alterations in the foot (Brothwell and Browne 2002; Gladykowska-Rzeczycka and Smiszkiewicz-Skwarska 1998; Kozlowski and Piontek 2000; Martin and Potts 2012; Mitchell 1900; Novak et al. 2014; Ortner 2003; Phillips 2001; Schrenk and Martin 2016; Stirland 1997; Tesorieri 2016; A. R. Thompson 2014; Wells 1964; Winkler and Gro[beta]schmidt 1988). Of these, only shortened and atrophic limb bones and possible hip dislocation were noted for B34. However, fragmentation and other taphonomic changes made detailed observations difficult on the proximal left femur, vertebrae, and foot bones.

Several aspects of B34's suite of conditions, as well as the biosocial context in which she or he lived, make hemiplegic CP the more probable diagnosis. While hemiplegia is possible with paralytic poliomyelitis, it is more common to have paralysis in one limb (particularly the leg) or both legs and/or both arms (Levine 1974). Furthermore, the possible avulsion injuries of the distal pole of the left patella and tibial tuberosities observed for B34 are both associated with knee conditions that increase tension of the patellar tendon in CP patients, such as spasticity of the quadriceps muscle, knee flexion contracture, patella alta, and walking on a flexed knee (Morrell et al. 2002). When present, knee involvement in polio most frequently includes flaccid paralysis of the joint or genu recurvatum (knee hyperextension), which would not place a great amount of strain on the patellar tendon (Chow et al. 2010; Fulkerson 2004; Herring 2014). Similarly, musculoskeletal impairment of the elbow in polio patients most often involves flaccid paralysis of the elbow flexors (inability to flex the joint). The burial position of B34 (see Fig. 1) is also remarkably similar to the typical posture of hemiplegic CP, namely, internal rotation and adduction of the shoulder, elbow flexion, forearm pronation, flexion of the wrist and fingers, flexion and internal rotation of the hip, flexion of the knee, equinovarus/valgus, and dorsiflexion of the toes (Berker and Yalcin 2010:91; Koman et al. 2004:Fig. 1, 1620-1621). However, given B34's burial in a coffin, it should be noted that skeletal elements may have been displaced during decomposition (Duday 2006).

Patients at ESH would probably not have been admitted for musculoskeletal impairments alone; therefore it is likely that B34 had at least some amount of cognitive impairment, psychological/behavioral issues, or a seizure disorder. None of these are common in paralytic poliomyelitis (Marx et al. 2000; Modlin 2010); however, many of the non-motor conditions that frequently accompany hemiplegic CP (see Table 3) could have necessitated the types of care provided by the hospital.

Clinical and Functional Significance

Due to the wide range of symptoms commonly associated with hemiplegic CP, the majority of which would not manifest in the bone, it is not possible to determine the full extent of B34's impairments. However, given the bilateral limb length discrepancies as well as atrophy observed, she or he probably experienced at least some amount of diminished mobility. While most hemiplegic CP patients are able to ambulate without assistance, more than 90% demonstrate perceptible motor impairment in the affected arm and/or leg (Uvebrandt 1988). Overall motor impairment (e.g., arm/hand function or gait) is considered moderate to severe in over 50% of patients, with approximately 40% having a significant limp. Some involvement of the seemingly unaffected limbs (e.g., hyperactive reflexes) is also detected in 44% of patients. Burial 34's left arm was likely fixed in the flexed position pulled in across the torso and she or he probably walked on a crouched left leg, possibly contributing to the squatting facet observed in the right ankle as she or he compensated for the difference in leg lengths.

Sensory problems such as astereognosis (loss of tactile recognition), prevalent to some degree in almost half of hemiplegic CP patients (Uvebrandt 1988), can greatly affect the ability to complete activities of daily living, especially when coupled with impaired hand function (Bleyenheuft and Gordon 2013). Tasks frequently identified by caregivers or clinicians as problematic include self-dressing, eating (using utensils, making a sandwich), managing personal hygiene (brushing teeth, bathing, toileting), and leisure (holding a book, catching a ball) (Berker and Yalcin 2010; Van Zelst et al. 2006; Volman 2005; Wallen et al. 2011).

Clinical presentations of hip injuries (such as the possible hip dislocation observed for B34) often include chronic anterior hip or groin pain, with occasional periods of acute pain following activity (Groh and Herrera 2009; D. Hunt et al. 2012). Patients commonly experience functional limitations such as difficulty navigating stairs or walking for any distance, are unable to tolerate prolonged sitting, and frequently walk with a limp. Knee conditions, such as avulsion injuries of the tibial tuberosity or inferior pole of the patella, can cause acute or chronic anterior knee pain and difficulty walking (D. M. Hunt and Macnicol 2010; Morrell et al. 2002). Symptoms usually subside with rest and physical therapy, and after growth is complete they often spontaneously resolve.

Other associated non-motor conditions (i.e., cognitive impairment, epilepsy, vision problems, hearing or speech impairments, and behavioral or perceptual disorders), which are often interrelated and synergistic, occur in at least 42% of hemiplegic CP patients, with approximately one out of five exhibiting more than one (Uvebrandt 1988). Given her or his residence at the hospital, the most likely conditions present for B34 are impaired cognition or a seizure disorder, which are reported in 18-41% and 22-44% of cases, respectively (Uvebrandt 1988:Table 19, Table 20, 71).

Malnutrition is a risk for children with hemiplegic CP, especially during the first three years of life, resulting in stunted growth and weight faltering in 20% of patients (Stallings et al. 1993). Nutritional status tends to improve with age, likely owing to improvements in gross motor and oromotor skills (e.g., hand function, mastication, swallowing, etc.). The porosity in B34's orbital roofs consistent with cribra orbitalia could reflect nutritional deficiency during infancy or early childhood (Stuart-Macadam 1985; Walker et al. 2009); however, skeletal lesions documented in other bioarchaeological samples from the region suggest that malnutrition during the nineteenth century was not uncommon (Pollack et al. 2009, 2011). The parafunctional wear patterns and chipping observed in B34's dentition suggest bruxism (tooth-clenching or grinding), common in CP, which may occur as a result of malocclusion, masticatory muscular impairments, digestive issues, or anxiety (Ortega et al. 2007; Peres et al. 2007; Rosenbaum et al. 1966), as well as unilateral facial muscle weakness, which occurs in 30% of hemiplegic CP patients (Uvebrandt 1988).

The prevalence of musculoskeletal pain is significantly higher among individuals with CP than the general population, with hemiplegic patients reporting pain most often in the back, neck, shoulder, foot/ankle, and knee (Jahnsen et al. 2004). Chronic or substantial fatigue is also common, affecting between one in seven to over one-quarter of hemiplegic CP patients (Jahnsen et al. 2003).

Cerebral Palsy in the Nineteenth Century

Before constructing a model of care for B34, the clinical and functional significance of her or his conditions need to be further contextualized. The samples included in the clinical literature referenced in the discussion above were drawn from modern healthcare settings in which patients likely received medical interventions (e.g., occupational or physical therapy, surgery, medications such as anti-epileptic drugs or analgesics, etc.). Moreover, public perception of disability has changed drastically since the nineteenth century. With the implementation of the Rehabilitation Act of 1973 and the Americans with Disabilities Act in 1992, both of which were largely the product of public support and demand, rights and opportunities for individuals with psychological, cognitive, or physical disabilities are now available (e.g., housing, employment, education, building/facility accessibility, etc.) that would have been nonexistent in the nineteenth century (Switzer 2003).

During the 1800s, independent community living was likely not possible for many individuals with physical and/or cognitive disabilities (Barnes 1991; R. F. White 1984). In the absence of the resources available today, an individual with hemiplegic CP may not have been able (or expected) to work outside the home (or institutional setting) in order to contribute to the economic well-being of her or his family.

While cerebral palsy was not formally recognized as a condition until the late nineteenth century (Little 1862; Osler 1889), treatments were available for the symptoms known to be associated with CP today. For example, spasticity and joint contracture were often subdued with massage and physical manipulation, heat or electrical stimulation, and herbal or pharmaceutical remedies (Little 1843, 1853). Mobility aids available at the time included modified (raised or reinforced) shoes, crutches or canes, and wheelchairs. Surgical interventions (e.g., tenotomy or tendon release) were often successful in reducing debilitating muscle contractures of the hip, knee, ankle, elbow, and hand; however, such procedures were primarily reserved for the wealthy. Individuals with epilepsy were often prescribed anti-seizure medications (e.g., castor, mugwort, absinthe, and potassium bromide [after 1857]) (Magiorkinis et al. 2014; Okoh-Esene et al. 2013). Trephination was also employed for seizures throughout the nineteenth century (R. F. White 1984).

Discussion: A Model of Care for Burial 34

Taken together, the dynamic motor and non-motor impairments and conditions that comprise the hemiplegic CP sequelae can influence and permeate every aspect of the individual's life. The clinical presentations are highly variable based on the severity of the initial insult or injury to the brain, the area of the brain affected, and the progression of musculoskeletal involvement over time. However, given the pathological conditions observed in the skeleton, she or he likely required some amount of care or accommodation of difference. Because B34 was a patient at ESH, the question of whether she or he received care is not in dispute. What we do not know is how long she or he was a patient and what, specifically, her or his care comprised.

Burial 34 would have shown symptoms of the disorder during the first few years of life as she or he fell behind peers in reaching developmental milestones (Uvebrandt 1988). If she or he was cared for at home throughout childhood, family members would probably have been able to adapt to evolving needs as mobility issues changed. While B34's care may have been manageable for family members early on, the challenges would have increased considerably after puberty (Raina et al. 2005), and even more so after sustaining the recent left hip injury, possibly contributing to her or his ultimate institutionalization.

At a minimum, as a patient at ESH, B34 would have received direct support in the form of housing, food and water, clothing, and other provisions. If B34 had been unable to perform any of the daily activities expected of all residents, attendants would have been available to provide assistance (EKLA 1859:22). For instance, as a result of the musculoskeletal impairments, she or he may have required at least some help dressing or attending meals in the dining rooms.

Following the relatively recent left acetabular injury, B34 would certainly have experienced further limitations to completing essential tasks of everyday life, such as standing or walking, maintaining personal hygiene, voiding bladder/bowels, and self-dressing. Burial 34's walking and balance issues, which were likely significant before the injury, would have necessitated some amount of therapy if she or he were to regain prior mobility. The lack of atrophy in the bones of the right arm and leg suggest that B34 was not completely immobile for any substantial period of time. A walking aid (e.g., crutch or cane) may have been used to provide added stability.

The hospital provided opportunities for patients to participate in social activities, such as weekly religious services, annual celebrations, and carriage trips to the city (EKLA 1844:631). All patients were required to spend time outside each day, whether to participate in games or for daily strolls, as fresh air was considered essential to any therapeutic regimen (EKLA 1843:457). While most of the patients were assigned labor associated with the hospital's work program as an integral part of moral therapy, B34's motor impairments may have excused her or him from such tasks. If she or he was unable to work or exercise independently, attendants would have been expected to facilitate some form of exercise outdoors for at least two hours per day (EKLA 1843:457).

Burial 34 may have been prescribed medications for treatment of symptoms specific to her or his pathological conditions, such as opiates for pain or mugwort to subdue seizures. Many of the leisure or labor-related activities expected of patients are similar to those used by occupational therapists to improve overall mobility and fine motor skills in patients today (Berker and Yalcin 2010; Miller 2007). If B34 was a resident earlier in life, these could have been beneficial in slowing the progression of muscle impairment.

Given the prevalence of diarrhea and other illnesses, the risk of infection combined with the dangerous side effects of many of the prescribed treatments (e.g., bloodletting, often toxic doses of mercurous chloride for purgation [R. F. White 1984]) were an ever-present risk for all residents at the hospital. This is especially relevant for B34, as CP patients are particularly susceptible to infection (Colver et al. 2014).


The differential diagnosis and bioarchaeology of care analysis presented here demonstrates the methodological and theoretical utility of such investigations for understanding the experience of disability and care provision in institutional contexts. This study illustrates the challenges inherent in constructing a care model for an individual with long-term progressive impairments residing at a mental-health hospital.

The conditions that frequently accompany CP can interfere with "daily function, independence, mobility, and overall health" (Sawyer 2013:1208). While this was likely the case for B34, we cannot know the full extent that her or his disability affected day-to-day life, as most of the associated conditions of CP do not manifest in the bones, and the symptoms, progression of the musculoskeletal involvement, and prognosis are unique for each patient. The fact that B34 was a resident at ESH, for whatever length of time, indicates that some amount of care or accommodation of difference was provided. However, it is likely that the quality of care was not evenly distributed among residents, as those from wealthy families may have had access to higher levels of care (e.g., larger, single rooms with accommodations to which they were accustomed [Pollack and Worne 2014; R. F. White 1984]). While this tiered system would not necessarily have mitigated the physical risks that treatments presented or the negative public perceptions of so-called deviants, some residents may have experienced different forms of therapies. Although moral treatment was considered a kinder approach to care than previously established practices (EKLA 1843; Yanni 2007), many have criticized its supposedly more humane approach as simply replacing the physical restraints of the past with new methods of social control that sought to normalize those considered socially deviant and mold them into more productive members of society (Foucault 2006; Goffman 1968).

One of the most significant obstacles for individuals with hemiplegic CP during the mid-1800s would have been overcoming society's preconceived ideas about what they were capable of achieving (Berker and Yalcin 2010; Murphy et al. 2000). At the time, individuals with physical or psychological disabilities were often blamed for their condition and deemed not to be entitled to the same rights as those considered sane or able-bodied (Barnes 1991; Grob 1994; R. F. White 1984). Prevailing views at the time are illustrated in a letter from the hospital's building committee to the people of Kentucky in which they argue that the "poor, disabled, and infirm members of society" could, with the care provided by a public hospital, "become useful to themselves, to their families and to society" and that "society itself would be made more secure against the wild and desperate actions of lunatics, if provision was made to contain them within its walls" (Kentucky Reporter 1816:3). While providing care was part of the hospital's stated mission, and it was believed that many patients could be cured of their maladies, segregating individuals deemed dangerous or unfit was clearly a motivating factor.

In addressing some of the issues encountered regarding care analysis of historical institutionalized individuals and long-term progressive conditions, this case highlights the connections between the specific biocultural context of disability and social forms of care provision. By incorporating historical information concerning the institutional context as well as past philosophies about disability and care, this study provides the context necessary to offer a more holistic view into what life was like for B34, demonstrating that a more robust bioarchaeology often emerges through an interdisciplinary approach.


A special thanks to David Pollack, Stuart Nealis, Emily Rinker, Mindi Wetzel, and other Kentucky Archaeological Survey field and laboratory staff who made this work possible. I am grateful to Mary Lucas Powell, Erin Koch, Janet Mansfield, Erin Guthrie, Hilary Jarvis, and Anna-Marie Casserly for their feedback on early drafts of this manuscript. I would also like to thank the Kentucky Finance and Administration Cabinet, Bluegrass Community and Technical College, Kentucky Cabinet for Health and Family Services, and the Eastern State Hospital staff.

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Heather Worne (a)*

(a) Department of Anthropology, University of Kentucky, Lexington, KY 40506

(*) Correspondence to: Heather Worne, Department of Anthropology, 211 Lafferty Hall, University of Kentucky, Lexington, KY 40506-0024


Received 27 September 2016

Revised 25 May 2017

Accepted 27 May 2017

DOI: 10.5744/bi.2017.1010
Table 1. Comparison of Right and Left Long Bone Measurements (in

Measurement                                  Left  Right

Humerus: Maximum length                      290   308
Humerus: Maximum diameter at midshaft         17    21
Humerus: Minimum diameter at midshaft         15    16
Humerus: Epicondylar breadth                  57    59
Femur: A-P subtrochanteric diameter           22    28
Femur: M-L subtrochanteric diameter           20    27
Tibia: Maximum diameter at nutrient foramen   29    35
Tibia: M-L diameter at nutrient foramen       19    23
Tibia: Circumference at midshaft              80    96

Table 2. Summary of Neuromuscular Disorders Considered in the
Differential Diagnosis

Neuromuscular   Characteristics

Duchenne        * X-linked recessive neuromuscular disorder
Muscular          affects approximately1/3,500 live male births today.
Dystrophy       * Muscle weakness is symmetrical and progressive.

                * Common associated conditions: contractures,
                  alterations in gait,scoliosis.
                * Patients generally unable to walk by 12 years of age.

                * Other nonmotor conditions: impaired cognitive
                  function, cardiomyopathy, pulmonary involvement.
                * Death usually occurs by late adolescence or early
                  twenties (due to respiratory infection, compounded
                  by cardiomyopathy), especially in the absence of
                  modern medical intervention.
Female          * Usually asymptomatic.
Carriers of     * Approximately 5-10% of female carriers of the DMD
DMD               show mild symptoms of the DMD disorder, with onset
                  occurring at any age (i.e., 2-74 years).
                * When present, muscle weakness is usually asymmetrical
                  and mild (although onset before age 15 often results
                  in more severe involvement).
Paralytic       * Poliomyelitis is a neurotropic viral infection of the
Poliomyelitis     genus Enterovirus genus Enterovirusmost often spread
                  through fecal-oral transmission. The poliovirus
                  initially infects the respiratory or gastrointestinal
                  tracts, potentially invading the central nervous
                  tissue, particularly the anterior horn of the spinal
                  cord and motor nuclei in the brainstem.
                * Illness manifestation can range from asymptomatic
                  (90-95% of cases) to severe paralysis. Paralytic
                  poliomyelitis results from roughly 0.1% of all
                * Permanent muscle damage occurs in approximately
                  two-thirds of paralytic poliomyelitis patients.
                * The paralysis is characteristically flaccid,
                  asymmetrical, and patchy in its distribution.
                * Associated musculoskeletal conditions: contractures,
                  bone and muscle atrophy, disruptions in normal bone
                  growth and development, scoliosis; musculoskeletal
                  alterations of the hip (hip dysplasia, femoral neck
                  anteversion, coxa valga), knee (genu recurvatum,
                  flail knee), and foot (equinovalgus/varus).
Hemiplegic      * Causative factors: perinatal ischemic stroke,
Cerebral Palsy    congenital malformations, abnormal uterine growth,
                  maternal fever or infection during delivery, other
                  complications associated with multiple births or
                  premature delivery.
                * Damage to the brain is non-progressive and permanent.
                * Hemiplegic CP affects upper and lower limbs on one
                  side of the body, with upper extremity usually more
                * Hemiplegia occurs in approximately 23-30% of CP
                * Associated musculoskeletal conditions: contractures,
                  disruptions in bone growth and development, scoliosis,
                  impairments of the knee and hip (hip dysplasia,
                  femoral neck anteversion), skeletal changes in the
                  foot, and osteoarthritis.
                * Other associated non-motor conditions: seizure
                  disorders, impaired cognitive development or learning
                  disabilities, sensory and perceptual problems,
                  osteopenia and increased fracture risk, difficulty
                  maintaining personal hygiene.
Neuromuscular   References

Duchenne        Emery 1991
Dystrophy       Karol 2014b; Thompson and Berenson 2006;
                Warner and Sawyer 2013
                Karol 2014b; Thompson and Berenson 2006; Walton
                and Warrick 1954; Warner and Sawyer 2013
                Emery 2002; Karol 2014b; Thompson and Berenson
                2006; Warner and Sawyer 2013
                Karol 2014b; Warner and Sawyer 2013

                Emery 2002; Karol 2014b; Thompson and Berenson
                2006; Warner and Sawyer 2013

Carriers of     Hoogerwaard et al. 1999; Juan-Mateu et al. 2012;
DMD             Song et al. 2011

Paralytic       Herring 2014; Modlin 2010

                Herring 2014; Modlin 2010

                Modlin 2010

                Chow et al. 2010; Modlin 2010; Sharrard 1955

                Chow et al. 2010; Currarino 1966; Herring 2014

Hemiplegic      Karol 2014a; Nelson 2008; Sawyer 2013
Cerebral Palsy

                Koman et al. 2004; Sawyer 2013

                Koman et al. 2004; Sawyer 2013

                Fawcitt 1964; Morrell et al. 2002; Sawyer 2013

                Koman et al. 2004; Sawyer 2013; Uvebrandt 1988

Table 3. Conditions Commonly Associated with Spastic Hemiplegic
Cerebral Palsy

Associated Conditions                     Frequency among
                                          Hemiplegic Patients

Impaired cognition (IQ < 70)                        18-41%
Specific learning disabilities                         36%
Epilepsy                                            22-44%
Impaired stereognosis                                  44%
(loss of tactile recognition)
Hearing difficulties                                    7%
Speech impairment                                   20-30%

Vision impairment:  Strabismus                         20%
                    Other vision                       14%
Difficulties feeding/eating                         33-64%

Malnutrition                                           20%
(i.e., growth stunting, or
weight faltering)
GERD (gastroesophageal reflux disease)              22-56%
Urinary incontinence                                   20%
Psychiatric  Emotional disorders (i.e.,                25%
disorders:   anxiety or depression)
             Conduct disorders                         24%
             Hyperactivity (pervasive or            10-13%
Fatigue (chronic or substantial)                    14-27%

Musculoskeletal pain                      [greater than
                                          or equal to] 47%

Associated Conditions                     References

Impaired cognition (IQ < 70)              Uvebrandt 1988
Specific learning disabilities            Frampton et al. 1998
Epilepsy                                  Uvebrandt 1988
Impaired stereognosis                     Uvebrandt 1988
(loss of tactile recognition)
Hearing difficulties                      Uvebrandt 1988
Speech impairment                         Odding et al. 2006;
                                          Uvebrandt 1988
Vision impairment:  Strabismus            Uvebrandt 1988
                    Other vision          Uvebrandt 1988
Difficulties feeding/eating               Reilly et al. 1996;
                                          Sullivan et al. 2000
Malnutrition                              Stallings et al. 1993
(i.e., growth stunting, or
weight faltering)
GERD (gastroesophageal reflux disease)    Bozkurt et al. 2004
Urinary incontinence                      Odding et al. 2006
Psychiatric  Emotional disorders (i.e.,   Goodman and Graham 1996
disorders:   anxiety or depression)
             Conduct disorders            Goodman and Graham 1996
             Hyperactivity (pervasive or  Goodman and Graham 1996
Fatigue (chronic or substantial)          Jahnsen et al. 2003

Musculoskeletal pain                      Jahnsen et al. 2004
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Author:Worne, Heather
Publication:Bioarchaeology International
Date:Sep 22, 2017
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