MEDIEVAL CARE OF THE INSANE

Quite contrary to the usual impression, rather extensive and well-managed institutions for the care of the insane came into existence during the Middle Ages, and continued to fulfil a very necessary social and medical duty. For the unspeakable neglect of the insane which is a disgrace to civilization, we must look to the centuries much nearer our own than those of the Middle Ages. Above all, the Middle Ages did not segregate the insane entirely from other ailing patients until their affections had become so chronic as to be certainly incurable, and they took the insane into ordinary hospitals to care for them at the beginning of their affection. This mode of procedure has many advantages, mainly in getting the patients out of unfavourable environments and putting them under skilled care early in their affections, so that a definite effort is being made to restore what is called the psychopathic ward in the general hospitals in our time. Only a careful study of the details of actual historical references to the medieval care of the insane will serve to contradict unfortunate traditions which have gathered around the subject entirely without justification in real history.

The traditions of medical knowledge with regard to the insane inherited by the early Middle Ages from the ancients were of the best, and the books written at this time have some interesting material on the subject. Paulus AËgineta (AËginetus), who wrote in the seventh century—and it must not be forgotten that already at this time some 200 years of the Middle Ages have passed—has some excellent directions with regard to the care and treatment of patients suffering from melancholia and mania. He says, in his paragraph on the cure of melancholy: “Those who are subject to melancholy from a primary affection of the brain are to be treated with frequent baths and a wholesome and humid diet, together with suitable exhilaration of mind, and without any other remedy unless, when from its long continuance, the offending humour is difficult to evacuate, in which case we must have recourse to more powerful and complicated plans of treatment.” He then gives a series of directions, some of them quite absurd to us, apparently in order to satisfy those who feel that they must keep on doing something for these cases, though evidently his own opinion is expressed in the first portion of the paragraph, and in the simple laxative treatment that he outlines. “These cases are to be purged first with dodder of thyme (epithymus) or aloes; for if a small quantity of these be taken every day it will be of the greatest service, and open the bowels gently.”

His directions as to diet for those suffering from melancholia are all in the line of limiting the consumption of materials that might possibly cause digestive disturbance, for evidently his experience had taught him that the depression was deeper whenever indigestion occurs. He says: “The diet for melancholics shall be wholesome and moderately moistening; abstaining from beef, roe’s flesh, dried lentils, cabbages, snails, thick and dark coloured wines, and in a word from whatever things engender black bile.” Mania was to be treated very nearly like melancholia, with special warnings as to the necessity for particular care of these patients. “But above all things they must be secured in bed, so that they may not be able to injure themselves or those who approach them; or swung within a wicker basket in a small couch suspended from on high.” This last suggestion would seem to be eminently practical, especially for young people who are not too heavy, and enforces the idea that the physicians of this time were thinking seriously of their problems of care for the insane and exercising their ingenuity in inventions for their benefit.

Paul of Ægina seems, then, to have thought that mania and melancholia were definitely related to each other, and to have held a similar opinion in this regard to AretÆus, who declared that melancholia was an incipient mania. Both had evidently noted that in most cases there were melancholic and maniacal stages in the same patient. These early medieval students of mental disease, then, anticipated to a rather startling extent our most recent conclusions with regard to the essential insanities. They would have been much readier to agree with Kraepelin’s term, manic-depressive insanity, than with the teaching of the hundred years before our time, which so absolutely separated these two conditions.

All this represents an organized knowledge of insanity that could not be acquired by chance, nor by a few intermittent observations on a small number of patients, but must have been due to actual, careful, continued observation of many of them over a long period. Here is the presumptive evidence for the existence of special institutions for their care at this period in the Middle Ages. This presumption is confirmed by Ducange in his “Commentary on Byzantine History,” in which he tells of the existence of a morotrophium, or house for lunatics, at Byzantium in the fourth century, and one is known to have existed at Jerusalem late in the fifth century. Further confirmation of the existence of special arrangements and institutions for the care of the insane even thus early in the Middle Ages is obtained from the regula monachorum of St. Jerome, which enjoins upon the monks the duty of making careful provision for the isolation and proper treatment of the sick both in mind and body, whilst they were enjoined to leave nothing undone to secure appropriate care and speedy recovery of such patients.[16]

Among the first Christian institutions for the care of the ailing founded by private benevolence, a refuge for the insane was undoubtedly built in England before the seventh century. Burdett says that: “How far the two institutions established in England prior to A.D. 700 were entitled to be considered asylums, we have discovered insufficient evidence to enable us to decide.” He evidently inclines to the opinion, however, that provision was made in them for the care of those ailing in mind as well as in body.

There is a rather well-grounded tradition that Sigibaldus, the thirty-sixth bishop of Metz during the papacy of Leo IV., about A.D. 850, erected two monasteries and paid special attention to the sick in body and mind. There are records that the insane in Metz were placed under the guardianship of persons regularly appointed. The attendants in the hospitals had to take a special oath of allegiance to the King, and that they would fulfil their duties properly.

There is definite evidence of Bethlehem in London, afterwards known as Bedlam, containing lunatics during the thirteenth century, for there is the report of a Royal Commission in the next century stating that there were six lunatics there who were under duress. Burdett says that Bedlam has been devoted exclusively to the treatment of lunatics from some years prior to 1400 down to the present time, so that it takes precedence in this matter of the asylum founded in Valencia in Spain, which Desmaisons has erroneously held as the first established in Europe. Esquirol states that the Parliament of Paris ordered the general hospital, that of the Hotel Dieu, to provide a place for the confinement of lunatics centuries before this; and while definite evidence is lacking, there seems no doubt that in most places there were, as we have said, what we would call psychopathic wards in connection with medieval hospitals.

Early in the fifteenth century there are a number of bequests made to Bedlam which specifically mention the care of the insane. Indeed, “the poor madmen of Bethlehem” seem to have been favourite objects of charity. The care of the insane there seems to have touched a responsive chord in many hearts. Mayor Gregory describes in his “Historical Collections” (about 1451) this London asylum and its work of mercy, and from him we have evidence of the fact that some of the patients were restored to reason after their stay in the asylum. He has words of praise for how “honestly” the patients were cared for; but recognizes, of course, that some could not be cured. In his quaint old English he emphasizes particularly the church feature of the establishment.

“A chyrche of Owre Lady that ys namyde Bedlam. And yn that place ben founde many men that ben fallyn owte of hyr wytte. And fulle honestely they ben kepte in that place; and sum ben restoryde unto hyr witte and helthe a-gayne. And sum ben a-bydyng there yn for evyr, for they ben falle soo moche owte of hem selfe that hyt ys uncurerabylle unto man.”

In her chapter on Hospitals for the Insane in “Medieval Hospitals of England,”[17] Miss Clay gives a number of details of the care of the insane in England, and notes that the Rolls of Parliament (1414) mention “hospitals ... to maintain men and women who had lost their wits and memory”; manifestly they had some experience which differentiated cases of aphasia from those of insanity. She says that outside of London “it was customary to receive persons suffering from attacks of mania into general infirmaries. At Holy Trinity, Salisbury, not only were sick persons and women in childbirth received, but mad people were to be taken care of (furiosi custodiantur donec sensum adipiscantur). This was at the close of the fourteenth century. In the petition for the reformation of hospitals (1414), it is stated that they existed partly to maintain those who had lost their wits and memory (hors de leur sennes et mÉmoire).”

Further evidence of the presence of the insane with other patients is to be found in the fact that in certain hospitals and almshouses it was forbidden to receive the insane, showing that in many places that must have been the custom. Miss Clay notes:

“Many almshouse-statutes, however, prohibited their admission. A regulation concerning an endowed bed in St. John’s, Coventry (1444), declared that a candidate must be ‘not mad, quarrelsome, leprous, infected.’ At Ewelme ‘no wood man’ [crazy person] must be received; and an inmate becoming ‘madd, or woode,’ was to be removed from the Croydon almshouse.”

Desmaisons is responsible for the tradition which declares there were no asylums for the insane until the beginning of the fifteenth century, and that then they were founded by the Spaniards under the influence of the Mohammedans. Lecky, in his “History of European Morals,” has contradicted this assertion of Desmaisons’, and declares that there is absolutely no proof for it. Burdett, in his “History of Hospitals,” vol. i., p. 42, says with regard to this question:

“Again, Desmaisons states that the ‘origin of the first establishment exclusively devoted to the insane dates back to A.D. 1409. This date constitutes an historic fact, the importance of which doubtless needs no demonstration. Its importance stands out all the more clearly when we calculate the lapse of time between the period just spoken of (1409) and that in which Spain’s example’ (Desmaisons is here referring to the Valencia asylum as the first in Europe) ‘found so many followers.’ Now, as a matter of fact, an asylum exclusively for the use of the mentally infirm existed at Metz in the year A.D. 1100, and another at Elbing, near Danzic, in 1320. Again, there was an ancient asylum, according to Dugdale, known as Berking Church Hospital, near the Tower of London, for which Robert Denton, chaplain, obtained a licence from King Edward III. in A.D. 1371. Denton paid forty shillings for this licence, which empowered him to found a hospital in a house of his own, in the parish of Berking Church, London, ‘for the poor priests, and for men and women in the said city who suddenly fall into a frenzy and lose their memory, who were to reside there till cured; with an oratory to the said hospital to the invocation of the Blessed Virgin Mary.’”The passages from AËgineta at the beginning of this chapter represent a thorough understanding of mental diseases often supposed not to exist at this time. Often it is presumed that this thorough appreciation of insanity gradually disappeared during subsequent centuries, and was not revived until almost our own time. It is quite easy, however, to illustrate by quotations from the second half of the Middle Ages a like sensible treatment of the subject of insanity by scientific and even popular writers. How different was the attitude of mind of the medieval people toward lunacy from that which is usually assumed as existing at that time may be gathered very readily from the paragraph in “Bartholomeus’ EncyclopÆdia” with regard to madness. I doubt whether in a brief discussion so much that is absolutely true could be better said in our time. Insanity, according to old Bartholomew, was due to some poison, autointoxication, or strong drink. The treatment is prevention of injury to themselves or others, quiet and peaceful retirement, music, and occupation of mind. The paragraph itself is worth while having near one, in order to show clearly the medieval attitude toward the insane of even ordinarily well-informed folk, for Bartholomew was the most read book of popular information during the Middle Ages.Bartholomew himself was only a compiler of information—a very learned man, it is true, but a clergyman-teacher, not a physician. Translations of his book were probably more widely read in England, in proportion to the number of the reading public, than any modern encyclopÆdia has ever been. He said:

“Madness cometh sometime of passions of the soul, as of business and of great thoughts, of sorrow and of too great study, and of dread: sometime of the biting of a wood-hound [mad dog], or some other venomous beast; sometime of melancholy meats, and sometime of drink of strong wine. And as the causes be diverse, the tokens and signs be diverse. For some cry and leap and hurt and wound themselves and other men, and darken and hide themselves in privy and secret places. The medicine of them is, that they be bound, that they hurt not themselves and other men. And namely such shall be refreshed, and comforted, and withdrawn from cause and matter of dread and busy thoughts. And they must be gladded with instruments of music and some deal be occupied.” (Italics ours.)

Bartholomew recognizes the two classes of causes of mental disturbance, the mental and the physical, and, it will be noted, has nothing to say about the spiritual—that is, diabolic possession. Writing in the thirteenth century, diabolism was not a favourite thought of the men of his time, and Bartholomew omits reference to it as a cause of madness entirely. Food and drink, and especially strong spirituous liquor, are set down as prominent causes. It may seem curious in our time that the bite of a mad dog, or a “wood hound,” as Bartholomew put it, should be given so important a place; but in the absence of legal regulation rabies must have been rather common, and the disease was so striking from the fact that its onset was often delayed for a prolonged interval after the bite, that it is no wonder that a popular encyclopÆdist should make special note of it.

The effect of alcohol in producing insanity was well recognized during the Middle Ages, and many writers have alluded to it. Pagel, in the chapters on Medieval Medicine in Puschmann’s “Handbook,” says that Arculanus, of whom there is mention in the chapter on Oral Surgery and the Minor Surgical Specialities, has an excellent description of alcoholic insanity. The ordinary assumption that medieval physicians did not recognize the physical factors which lead up to insanity, and practically always attributed mental derangement to spiritual conditions, especially to diabolic possession, is quite unfounded so far as authoritative physicians were concerned. Their suggestions as to treatment, above all in their care for the general health of the patient and the supplying of diversion of mind, was in principle quite as good as anything that we have been able to accomplish in mental diseases down to the present time. Their insanity rate, and above all their suicide rate, was much lower than ours, for life was less strenuous and conscious, and though men and women often had to suffer from severe physical strains and stresses, their free outdoor life made them more capable of standing them.

The history of human care for the insane, it is often said by those who are reviewing the whole subject briefly, may be represented by the steps in progress from the presumption of diabolical possession, and exorcism for its relief, to intelligent understanding, sympathetic treatment, and gentle surveillance, with the implication that this has all been a gradual evolution. There is no doubt that during the Middle Ages even physicians often thought of possession by the devil as the cause of irrational states of mind. Not only some of the genuinely insane—though not all, be it noted—but also sufferers from dreads and inhibitions of various kinds, the victims of tics and uncontrollable habits, especially the childish repetition of blasphemous words, and sufferers from other psychoses and neuroses, were considered to be the victims of diabolic action. Exorcism then became a favourite form of treatment of all these conditions, but its general acceptance came about because it was so often successful. The mental influence of the ceremonies of exorcism was often quite as efficient in the cure of these mental states as mesmerism, hypnotism, psycho-analysis, and other mental influences in the modern time.

It may particularly be compared in this regard to psycho-analysis in our own day, for this cures patients by making them feel that they have been the victims of some very early evil impression, usually sexual in character, which has continued unconsciously to them to colour all their subsequent mental life. Some of the curious theories of secondary personality, the subliminal self and what has recently been called “our hidden guest,” represent in other terms what the medieval observers and thinkers expressed in their way by an appeal to diabolic influence. They felt that there was a spirit influencing these patients quite independent of themselves in some way, and their thoroughgoing belief in a personal devil led them to think that there must be some such explanation of the phenomena. Even great scientists in the modern time who have studied psychic research have not been able to get away entirely from the feeling that there is something in such possession, and have admitted that there may be even alien influence by an evil spirit. The more one studies the question from all sides, and not merely from a narrow materialistic standpoint, the less one is ready to condemn the medievalists for their various theories of diabolic possession. The Christian Church still teaches not only its possibility but its actual occurrence.

Such conservative thinkers as Sir Thomas More, one of England’s greatest Lord Chancellors, the only one who ever cleared the docket of the Court of Chancery, continued to believe in it nearly a century after the Middle Ages had closed, but above all is quite frank in the expression of his opinion that some of the mutism, the tics, and bad habits, and repeated blasphemies, attributed to it, may be cured by soundly thrashing the young folks who are subject to them. Neurological experts will recall similar experiences in the modern time. Charcot’s well-known story of the little boy whose tic was the use of the word uttered by the corporal at Waterloo, and was cured by being soundly licked by some playmates at the SalpÊtriÈre gate, is a classic. Some of the medieval cruelty represented unfortunate developments from the observations that had been made that a number of the impulsive neuroses and psychoneuroses could be favourably modified, or even entirely corrected, by attaching to the continuance of the habit a frequently repeated memory of distinctly unpleasant consequences that had come upon the patient because of it. Our experience in the recent war called to attention a great many cases of mutism, functional blindness, tremors, and incapacities of all kinds, some of which were cured by painful applications of electricity. The medieval use of the lash for such cases can be better understood now as the result of this very modern set of clinical observations.

In the meantime it must not be forgotten that the people of the Middle Ages, even when they thought of insane and psychoneurotic persons as the subjects of diabolic possession, felt themselves under the necessity of providing proper physical care for these victims of disease or evil spirits, and as we know actually made excellent provision for them. Not only were the insane given shelter and kept from injuring themselves and others, but in many ways much better care was provided for them than has been the custom down almost to our own time. They had many fewer insane to care for; life was not so strenuous, or rather fussy, as it is in our time; large city life had not developed, and simple existence in the country was the best possible prophylactic against many of the mental afflictions that develop so frequently in the storm and stress of competitive industrial city existence. This prophylaxis was accidental, but it was part of the life of the time that needs to be appreciated, since it represents one of the helpful hints that the Middle Ages can give us for the reduction of our own alarmingly increasing insanity rate.

They had no large asylums such as we have now, but neither did they have any poor-houses; yet we have come to recognize how readily they solved the social evils of poverty. The almshouses at Stratford, with their accommodations for an old man and his wife living together, are a typical, still extant example of this. Each small community cared for its own sufferers. They did not solve their social problems in the mass fashion which we have learned is so liable to abuse, but each little town cared to a great extent for its own mentally ailing. They were able to do this mainly because hospitals were rather frequent; and psychic cases were, at the beginning, cared for in hospitals, and when in milder state their near relatives were willing to take more bother in caring for them than in our time. Delirious states due to fever had not yet been definitely differentiated from the acute insanities, and all these cases then were taken in by the hospitals. This was an excellent thing for patients, because they came under hospital care early; and one of the developments that must come in our modern hospitals is a psychopathic ward in every one of them, for patients will be saved the worst developments of their affection.

The better-to-do classes found refuges for their non-violent insane in certain monasteries and convents, or in parts of monastic establishments particularly set aside for this purpose. When the patient was of the higher nobility, he was often put in charge of a monk or of several religious, and confined in a portion of his own or a kinsman’s castle and cared for for years. There are traditions of similar care for the peasantry who were connected with monastic establishments, and sometimes small houses were set apart for their use on the monastery grounds. As cities grew in extent, certain hospitals received mental patients as well as the physically ailing, keeping them segregated. After a time some of these hospitals were entirely set aside for this purpose. Bedlam in England, which had been the old Royal Bethlehem Hospital for the care of all forms of illness, came to be just before the end of the thirteenth century exclusively for the care of the insane. In Spain particularly the asylums for the insane were well managed, and came to be models for other countries. This development in Spain is sometimes attributed to the Moors, but there is absolutely no reason for this attribution, except the desire to minimize Christianity’s influence, even though this effort should attempt the impossible feat of demonstrating Mohammedanism as an organizer of charity and social service.

Some of the developments of their care for the insane in the Middle Ages are very interesting. Before this period closed, there was a custom established at Bedlam by which those who had been insane but had become much better were allowed to leave the institution. This was true, even though apparently there might be no friends to care for them particularly, or to guarantee their conduct or their return, in case of redevelopment of their symptoms. This amounted practically to the open-door system. The authorities of the hospital, however, made one requirement. Those who had been insane and were allowed to leave Bedlam were required to wear a badge or plate on the arm, indicating that they had been for some time in this hospital for the insane. These people came to be known as Bedlamites, or Bedlams, or Bedlamers, and attracted so much sympathy from the community generally that some of the ne’er-do-wells, the tramps and sturdy vagrants who have always been with the world as a problem quite as well as the insane, obtained possession of these insignia by fraud or stealth, and imposed on the charity of the people of the time.

It is easy to understand that wherever these patients were recognized by their badges as having been for a time in an asylum for the insane, they were treated quite differently from ordinary people. Though allowed to leave the asylum, and left, as it were, without surveillance, they were really committed to the care of the community generally. No one who knows the history is likely to irritate a person who has been insane, nor are such people treated in the same spirit as those who are supposed to have been always normal, but out of pity and sympathy they are particularly cared for. They are not expected to live the same workaday existence as mentally healthy individuals, but their pathway in life is smoothed as much as possible. Many an unfortunate incident in modern times is due to the fact that a previous inmate of an asylum is irritated beyond his power to control himself in the ordinary affairs of life by those who know nothing of his previous mental weakness. It is not unlikely that our open-door system will have to be supplemented by some such arrangement as this medieval requirement of a badge, and that we can actually get suggestions from the medieval people with regard to the care of the insane that will be valuable for us.

Another very interesting development of care for the mentally afflicted was the organization of institutions like the village of Gheel in Belgium, in which particularly children who were of low-grade mentality were cared for. This was practically the origin of what has come in our time to be called the colony system of caring for defectives. We now have colonies for imbeciles of various grades, and village systems of caring for them. At Gheel the system developed, it might be said, more or less accidentally, but really quite naturally. St. Dympna was an Irish girl-martyr whose shrine, said to be on the site of her martyrdom, existed in the village of Gheel. Her intercession was said to be very valuable in helping children of low-grade mentality. These were brought to the shrine, sometimes from a long distance, and when the prayers of relatives were not answered immediately the children were often left near the shrine in the care of some of the villagers, to have the benefit of the martyr’s intercession for a prolonged period. As a consequence of this custom, many of the houses of the village came to harbour one or more of these mentally defectives, who were cared for by the family as members of it.

The religious feelings, and particularly the impression that the defectives were under the special patronage of the patron saint of the village, not only kept them from being abused or taken advantage of in any way, but made them an object of special care. They were given various simple tasks to perform, and the public spirit of the community cared for them. It was only with the development of modern sophistication that the tendency to take advantage of social defectives came and special government regulations had to be made and inspectors appointed. This system of caring for these defective children, however, was eminently satisfactory. Other villages took up the work, especially in the Low Countries and in France. The village and colony system of caring for the insane, which we are now developing with so much satisfaction, was entirely anticipated under the most favourable circumstances, and with religious sanctions, during the Middle Ages. Not a few of the defectives, when they grew up, came to be attached in various humble occupations to monastic establishments. Here they were out of the current of the busy life around them, and were cared for particularly. They were not overworked but asked to do what they could, and given their board and clothes and the sympathetic attention of the religious. There are many more of such cases at the present time than are at all appreciated. They emphasize how much of this fraternal care there must have been in the Middle Ages.

Between the village system of caring for defectives, and the germ of the colony idea in their recognition of the value of the country or small town as a dwelling-place for those suffering from backwardness of mind or chronic bodily ills that disturb mentality, and the “open-door system” for the insane, as practised at Bedlam and other places, the Middle Ages anticipated some of the best features of what is most modern in our care for mental patients. Their use of severe pain as a corrective for the psychoneuroses, even when they thought of them in connection with diabolic possession, is another striking instance of their very practical way of dealing with these patients in a manner likely to do them most good. We have had to make our own developments in these matters, however, before we could appreciate the true value of what they were doing in the Middle Ages.