looking at mental diseases. For that matter, we have not even as yet.
The intelligent classes in the community are, as a rule, convinced of
the physical basis of mental diseases, but there are a {364} great
many people who still are inclined to think that some of them, at
least, are manifestations of some punitive force outside of the
patients themselves, or even some manifestation of ill-understood
forces quite apart from matter. Not all the thinking people of the
Middle Ages accepted all the absurd notions sometimes rehearsed in
this matter, but as in our own time, foolish traditions and
superstitions dominated the unthinking classes, which form still,
unfortunately, the great mass of mankind. We have had just the
opposite delusions forced upon our attention in our own day. Large
numbers, supposedly of intelligent people, have pretended to believe
or have definitely accepted the teaching that disease is nothing. This
is quite as foolish as attributing to spiritual agencies what has come
to be recognized as due to physical factors. It is to be hoped that
our generation and its thinking shall not be judged by future
generations to have been utterly foolish, just because a few millions
of us accepted Eddyism,--and it must be remembered that these are not,
as a rule, the uneducated. Another side of this question is even more
interesting, or at least has become so during the last twenty years. A
generation ago it was the custom to scoff not a little scornfully in
scientific circles, at the idea of admitting even the possibility of
the interference of immaterial or spiritual agencies, or of any other
intelligences or wills at work in the ordinary affairs of this life,
than those of men. This scornful attitude still continues to be the
pose of many students and teachers of science. It is by no means so
universal as it was, however. Strikingly enough, the converts from
this attitude of mind have come, not from the lower ranks of teachers
of science, but from among the very leaders in original {365} research
and scientific investigation. We may still continue to laugh at and
ridicule the medieval people for their admission of the activity of
spirits in ordinary mundane affairs, but if we do so, we must also
laugh at and ridicule just as much, such prominent leaders of
scientific thought and progress as Sir William Crookes, Mr. Alfred
Russell Wallace, Sir Oliver Lodge, Professor Charles Richet, the
distinguished French physiologist, Flammarion the astronomer, and even
of late years Professor Lombroso, the well-known Italian
criminologist, whose special doctrines as to crime and criminals would
apparently insure him against such theories as those of the
spiritualists. All of these men have confessed their belief not only
in the possibility of spiritual interference in this world of ours,
but insist that they have seen such interference, and are absolutely
convinced of its frequent occurrence.
This is a decided reaction from previous states of the scientific mind
on this subject, and represents a retroversion to medieval modes of
thought that may be deprecated by scientific investigators of
materialistic tendencies, but that cannot be neglected, and must not
be despised. When the results of these recent investigations are taken
into account, the opprobrium which has been heaped upon medieval
scholars and churchmen for the facility with which they accepted the
doctrine of the interference of spirits in human life, must be
minimized to such a degree, or indeed eradicated so entirely, that a
saner view of the whole situation as regards the relationship of the
spiritual and material world seems likely to prevail. It is easy and
cheap to reject without more ado and without serious consideration,
such evidence of spiritual manifestations as has {366} convinced these
leaders of scientific thought. But this rejection is not scientific,
nor does it show an open mind. What is needed is a calm review of the
situation, in order to see just where truth lies. It is not at either
extreme. It is not in too great credulity with regard to spiritual
interference, but certainly not at the opposite pole of the negation
of all spiritual influence in human life, that genuine progress in
knowledge is to come. This premised, we may take up the consideration
of the actual accomplishment of the Middle Ages with regard to the
insane, better prepared to appreciate their point of view and to get
at the significance of their attitude toward the mentally diseased.
There are two phases of this question of the attitude of even
intelligent men of the Middle Ages toward nervous and mental diseases,
that deserve to be studied, not superficially, but in their actual
relationships to the men of that time, and to our opinions at the
present day. These are: first, the question of the treatment of the
mentally afflicted, and second, the mystery of demoniacal possession
and its related phenomenon--mediumship, as we call it.
Personally, I was very much surprised some years ago, while collecting
material for a paper to be read before the International Guild for the
Care of the Insane, to find how many things that are most modern in
our methods of treating the insane, and that are among the desiderata
which are universally conceded to be most necessary for the
improvement of present conditions in our management of mental
diseases, were anticipated by the generations of the thirteenth to the
fifteenth centuries. It is not hard, for instance, to show that such
eminently desirable conditions as the {367} open door for mild cases,
the combination of the ordinary hospital with a ward for psychic
cases, the colony system for the treatment of those of lower
mentality, were all in existence in the Middle Ages and did good work.
The colony system particularly, as it comes to us from the Middle
Ages, has recently been studied very carefully, and this has given us
many valuable hints as to the methods that will have to be adopted in
other countries in modern times.
The conditions which developed at Gheel in Belgium have deservedly
attracted much attention in recent times, and have been the subject of
articles in the medical journals of nearly every country in the world,
because of the poignant realization by our generation that large
institutions, meaning by this large single buildings or closely
associated groups of buildings, are very unfavorable for the care of
the insane. In America, one of these articles was published in the
Journal of Nervous and Mental Diseases, and a second, written by my
friend, Dr. Jelliffe, who is the Professor of Mental Diseases in
Fordham University School of Medicine, was written after a special
visit paid to Gheel by him, in order to investigate conditions there.
Though the situation at Gheel now is practically identical with that
which originated there at least five centuries ago, there are many who
consider that similar conditions would be ideal for the treatment of
certain classes of the insane even in our own day. It is this sort of
interpretation of the work of these old-time philanthropists and
physicians that we need, and not the cheap condemnation which makes it
necessary for us to begin all over again in each generation.
In the light of this unexpected revelation and the {368} consequent
revolution of thought it suggests, a short review of the treatment of
the insane will not be out of place. It is usual for our
self-complacent generation to consider that it was not until our own
time that rational measures for the care of the insane were taken.
Most of the text-books on mental diseases that touch at all on the
historical aspects of the treatment question, are apt to say that the
evolution of methods for the treatment and cure of the insane might be
divided into four historical periods: First, the era of exorcism, on
the theory that insane patients were possessed of devils. Second, the
chain and dungeon era, during which persons exhibiting signs of
insanity were imprisoned and shackled in such a manner as to prevent
the infliction of injury upon others. Third, the era of asylums.
Fourth, the present era of psychopathic wards in general hospitals for
the acutely insane in cities, and colonies for the chronic insane in
the country, which is only just beginning to develop.
From this classification, the ordinary reader would suppose that
nothing at all was done for the insane during the first two periods,
except exorcism in one and confinement in the other. As a matter of
fact, the number of the harmlessly insane has always been much larger
than the violent, and the latter, indeed, constitute only a very small
portion of the mentally ailing at any period. Exorcism, as a rule, was
applied only to the violent and to the hysterical. In the asylums at
all times there were a number of patients who were not chained or
confined to any great degree, and unless one had shown some special
violent manifestation, severe measures were not taken. It is the
treatment of the great mass of the insane rather than of the few {369}
exceptional cases, that must be considered as representing the
attitude of mind of the generations of the Middle Age toward the
mentally afflicted, and not what they found themselves compelled to do
because of their fear and dread of violence.
For those who were mentally afflicted in a mild degree, abundant
suitable provision was made by the generations of the fourteenth and
fifteenth centuries. When historical writers suggest the contrary,
they are only making one of the usual assumptions from ignorance of
the details. Because in some cases insanity was supposed to be due to
possession by the devil, to say that, therefore, in all cases no
provision was made for the insane is nonsense. It is comparatively
easy to find, from records of the hospitals of the fourteenth and
fifteenth centuries, that there were what we now call psychopathic
wards for the acutely insane in the cities, and some colonies for the
chronic insane in country places.
Knowing nothing of this, Prof. White, for instance, says: "The stream
of Christian endeavor, so far as the insane were concerned, was almost
entirely cut off. In all the beautiful provision during the Middle
Ages for the alleviation of human suffering, there was for the insane
almost no care. Some monasteries indeed gave them refuge. We hear of a
charitable work done for them at the London Bethlehem Hospital in the
thirteenth century, at Geneva in the fifteenth, at Marseilles in the
sixteenth, by the Black Penitents in the South of France, by certain
Franciscans in Northern France, by the Alexian Brothers on the Rhine,
and by various agencies in other parts of Europe; but, curiously
enough, the only really important effort in the Christian Church {370}
was stimulated by the Mohammedans." This last clause is a slur on
Christianity absolutely without justification. As is true for all
broad generalizations, to ignore thus the work of caring for the
insane and the methods employed in earlier times, amounts to
deplorable injustice to generations whose provision for the sick of
every class was not only much more abundant, but more rational and
complete, than it has been our custom to recognize and acknowledge.
The earliest city hospitals that we know of were due to the fatherly
care and providence of that great Pope, Innocent III., whose
pontificate (1198-1213) has been more misunderstood than perhaps any
corresponding period of time in history. It was Virchow, the great
German pathologist, whose sympathies with the Papacy were very slight,
and whose attitude in the Kulturkampf in Germany showed him to be a
strenuous opponent of the Papal policy, who paid the high tribute to
Pope Innocent III. which we quote in the chapter on the Foundation of
City Hospitals. It was in connection with these hospitals founded by
Pope Innocent III., or the result of the movement initiated by him,
that the insane were cared for at first. This may seem to have been an
undesirable method, but at the present time there is an almost
universal demand on the part of experts in mental diseases for wards
for the mentally diseased in connection with city hospitals, because
admission is thus facilitated, treatment is begun earlier, the patient
is not left in unsuitable conditions so long, friends are readier to
take measures to bring the patient under proper treatment and
surveillance, and, as a consequence, more of the acutely insane have
the course of their disease modified at once, and more cures take
place than would otherwise be possible. Of course, this was {371} not
the idea of the original founder of the medieval hospitals, or even
the conscious plan of those who were in charge. They had to take the
mentally infirm because there was nowhere else for them to go at that
time. As a matter of fact, however, their simple method of procedure
was better in the end for the patient than is our more complex method
of admission to insane asylums, with its disturbing necessity for
formal examination of the patient under circumstances that are likely
to increase any excitement that he may be laboring under. And the
transfer to an institution bearing the dreaded name of asylum, or even
sanitarium (for that term has taken quite as ominous a meaning in
recent years) is sure to aggravate the patient's irritated state, and
to exaggerate symptoms which might otherwise be relieved by prompt,
soothing care, and by the consciousness that his ailment is being
treated rather than that he himself is being placed in durance.
An examination of the methods for the care of the insane in the Middle
Ages brings out clearly the fact, that the modern generation may learn
from those old Catholic humanitarians, whose hearts and whose charity
served so well to make up for any deficiencies of intellect or of
science the moderns would presume them to have labored under. There
are said to be three great desiderata for the intelligent care for the
insane:
First: The open door system, permitting patients who are not violent,
and who can be trusted even though they have many queer notions, to
come and go at will.
Second: The after care treatment of those who have been insane, to the
end that they may not be compelled to go back to strenuous lives of
toil; and above all, that they {372} may not be forced into the too
harrassing conditions of which their mental breakdown originally was
born.
Third: A colony system by which patients of lowered intelligence may
be cared for in the country, far away from the stress of city life,
and where, without the cares of existence pressing upon them, they may
be surrounded by gentle, patient, kindly friends who will make every
allowance for their peculiarities and strive to help them in their
up-hill struggles.
These desiderata are so absolutely modern that they have only been
formulated definitely with the beginning of the twentieth century.
Notwithstanding this apparent newness, I think that it will not be
difficult to show that the old-time methods of caring for the insane
partook, to a greater degree than would be suspected at the present
time, of these desirable qualities that modern science has come to
recognize as so indispensable for the rational care of the mentally
unbalanced. In saying this I do not wish to claim for the Middle Ages
accomplishments beyond their deserts. My idea is rather to write an
interpretation; to make clear from what we know of the details of the
care of the insane in the fourteenth and fifteenth centuries, that
unconsciously those generations, in their large-hearted charity,
anticipated what is best in our present system.
The first record in English medical literature of a home for the
insane is that of Bethlehem Royal Hospital, London, which has become
famous under the familiar shortened name of Bedlam, meaning a house or
place of confusion. Bethlehem was a general hospital into which during
the fourteenth century insane patients were admitted. There is a
historical record to the effect that at the beginning of the fifteenth
century a royal commission {373} investigated the methods of treating
the insane in vogue there, because there had been complaint of abuses
in the institution. Practically every century since there have been
written corresponding records of similar investigations. The trouble
seems always to have been that there were too few attendants properly
to take care of insane patients, and thus they had to be placed in
confinement in various ways, which inevitably led to abuses.
For a generation or longer after each exposure by a committee of
inspection, the evils of this system would be more or less tolerable;
then they would become unbearable once more and another investigation
would be demanded. I would like to feel that we have progressed in all
respects beyond these hit and miss methods, but any one familiar with
the present situation in the matter is quite well aware that there are
still many abuses that need correction, and inspection committees find
many suggestions to make and sometimes gross evils to stigmatize.
Bedlam seems, however, to have always been as well and as humanely
conducted as the spirit of the times demanded. It must not be
forgotten that according to well authenticated tradition, a very large
part of the hospital's income was obtained by the collection of fees
for the admittance of visitors who came to be amused by the vagaries
of the insane. The number visiting the asylum for this purpose must
have been enormous, for, though only a penny was charged for
admission, the resulting revenue is said to have amounted to four
hundred pounds sterling a year, showing that nearly one hundred
thousand persons had visited the institution.
From generations that were pleased to derive morbid amusement out of
the misfortunes of others, humanitarian {374} care of the insane could
not be reasonably expected; but in view of this custom it is difficult
to understand how there could have been at this period any great abuse
of patients, in the matter of severe punishments or inhuman restraint.
Some of the customs of the old-time hospitals were interesting. It was
believed that the one chance for an insane patient to recover lay in
trusting him somewhat, allowing him even to go unattended outside the
walls at times. Patients in Bedlam were permitted to go out alone
after they improved in health, and if they were poor they were allowed
to obtain their living by means of begging. In order that they might
more easily work upon public sympathy, they were permitted to wear tin
plates fastened to their arms. The wearers of these were called
"Bedlams," or "Bedlamites" or "Bedlam beggars," and tradition says
that they received much more consideration than ordinary beggars.
It may appear that this was dangerous liberty, but the ordinary person
is apt to consider as dangerous the open door treatment of the insane
which most alienists now hold to be the most commendable feature of
present day treatment. It seems reasonable that to permit patients to
go into the open air and sunshine was better than confining them in
the hospital, and doubtless the insignia which they wore especially
commended them to the care and alms and sympathy of the people.
Much has been said with regard to the alleged neglect and abuse of the
insane during the period of exorcism, because of the misunderstanding
of the cause of the disease. There are persons who consider
neurasthenia and major-hysteria as more or less modern forms of
nervous diseases, but it is more than probable that they {375} existed
with considerable frequency in the olden time. Many of these cases
would be cured by strong suggestions, that is, by the treatment
usually given to supposed possessed persons, and as we know that the
best possible treatment for certain forms of major-hysteria is to
frighten the patient (the earthquake at San Francisco cured a dozen
persons who had not been regarded as able to walk, some of them for
years), it is probable that a goodly number of the patients of the
past were cured by the rather heroic measures sometimes devised. Sir
Thomas More mentions such cases, and though himself eminently humane,
commends this method of treatment "in which such patients were
severely scourged and thoroughly aroused from their willfulness."
When psychiatrists talk slightingly of the old-time methods of caring
for the insane, it is well to recall that, considering the conditions
and limitations of scientific knowledge, they seem to have done very
well in those times. It has been the custom of critics to hold up to
ridicule that insane patients were sometimes taken to special shrines
in order that their ills might be cured by the direct interposition of
Heaven; or that the devil supposed to possess them, might be driven
out. It must not be forgotten, however, that such procedures were of
supreme utility in mild cases viewed merely from the human standpoint,
and without any appeal to the supernatural. The journey to a favorite
shrine, undertaken under conditions that gave variety to life and new
interests, together with the hope aroused while there, were sufficient
to help the patient physically and, not infrequently, mentally.
Some of the most distinguished specialists in mental diseases in
Germany, France and England are on record {376} as believing that one
of the most helpful agencies in the relief of certain symptoms of
mental disturbance, and even the cure of milder forms of insanity, is
confidence in the Almighty as expressed by prayer. At a meeting of the
British Medical Association two years ago, this idea was expressed
very forcibly by a distinguished specialist, and was concurred in by a
number of those at the meeting of the Section on Mental Diseases. He
said:
"As an alienist and one whose life has been concerned with the
suffering of the mind, I would state that of all hygienic measures
to counteract disturbed sleep, depressed spirits and all of the
miserable sequels of a distressed mind, I would undoubtedly give the
first place to the simple habit of prayer. * * * Such a habit does
more to calm the spirit and strengthen the soul to overcome mere
incidental emotionalism than any other therapeutic agent known to
me."
The medieval peoples realized this, and finding it beneficial, used it
to decided advantage in a large number of cases.