Diagnosis, Guardianship, and Residential Care of the Mentally Ill
in Medieval and Early Modern England
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Introduction and review to article:
(Diagnosis, Guardianship, and Residential Care of the Mentally Ill in Medieval and Early Modern England, Richard Neugebauer, American Journal of Psychiatry Dec 1989 AD)
Diagnosis, Guardianship, and Residential Care of the Mentally Ill in Medieval...
Richard Neugebauer, Ph.D., M.P.H.
Histories of psychiatry concerning preindustrial Europe emphasize demonologic beliefs and physical mistreatment of the insane. Records of an English legal incompetency jurisdiction demonstrate that both government officials and laymen accepted that psychiatric disorders had biological and psychosocial origins. This jurisdiction, which developed a social welfare dimension by the seventeenth century, offered benevolent protection for the insane. Private guardians arranged for the lodging and care of their wards in private homes. While physicians played little role in the certification process, the guardians made frequent use of their skills. Furthermore, some physicians with established reputations in psychiatry accepted patients into their homes for prolonged cures. (Am J Psychiatry 1989; 146:1580-1584)
The history of psychiatry from the Middle Ages down to the seventeenth century is often equated with demonologic beliefs about mental illness and with the persecution, abuse, or simple neglect of the insane (1-3). For many clinicians, this dismal view magnifies twentieth century advances in psychobiology and humanitarian treatment; for Szaszian antipsychiatrists, it documents the early ancestry of modern psychiatry's scapegoating of social deviants (4).
While these contending parties embrace divergent interpretations of the historical data, their shared evidence is heavily biased in favor of printed texts, for example, treatises on witchcraft. The manuscript records of an early English legal incompetency jurisdiction constitute a valuable corrective. These documents demonstrate that for centuries before the factory and the steam engine, Europeans appreciated the biological and psychosocial origins of mental illness and tried to ensure benevolent care of the insane. In addition, physicians with established reputations in "psychiatry" adopted the practice of accepting patients into their own homes for protracted stays. This paper summarizes the medieval and early modern policies and procedures of the incompetency jurisdiction.
Received March 29, 1989; accepted June 2, 1989. From the Gertrude H. Sergievsky Center, Faculty of Medicine, Columbia University; and the Epidemiology of Developmental Brain Disorders Department, New York State Psychiatric Institute, New York, N.Y. Address reprint requests to Dr. Neugebauer, Faculty of Medicine, Columbia University, 630 West 168th St., New York, NY 10032. Supported in part by Public Health Service award MH-57359 from NIMH and by Public Health Service research training fellowship award MH-13043 to the Psychiatric Epidemiology Training Program, Columbia University. Citations from the Public Record Office appear by permission of the Controller of Her Majesty's Stationery Office.
Medieval English society was based on the preservation and stable transmission of landed wealth. Consequently, as early as the thirteenth century, the king was entitled to take possession of the person and estate of mentally ill subjects who were incapable of managing their own affairs. Initially, royal officials exercised this jurisdiction informally. In 1540 a parliamentary statute vested it in the court of wards and liveries (5). Although the court was abolished in 1660, the jurisdiction has continued uninterrupted and currently resides in the court of protection (6).
NOSOLOGY AND DIAGNOSTIC CRITERIA
The jurisdiction employed two major medicolegal categories: "idiot" and "lunatic." "Idiot" denoted persons who were mentally subnormal from birth, without hope of improvement. "Lunatics" exhibited psychotic behavior but were judged capable of recovery(7, 8). Commissions examined such persons before a jury that ruled'on their sanity. Commissioners' certificates, jury reports, the papers of court officials, court decrees, and the petitions of persons bringing lunatics and idiots to the government's attention afford substantial evidence on past approaches to the problem of insanity (9).
Idiocy examinations involved visual inspection, together with questions on orientation, memory, intellect, and judgment. For example, at her interview in July 1383, Emma de Beston
"was . . . asked in what town she was, she said that she was at Ely. Being asked how many days there were in the week, she said seven but could not name them . . . . Being asked how many husbands she had had in her time she said three, giving the name of one only .... Being asked how many shillings there were in forty pence, she said she did not know . . . asked whether she would rather have twenty silver groats than forty pence, she said they were of the same value. (10)
The examiners concluded "that she was not of sound mind, having neither sense nor memory nor sufficient intelligence to manage herself, her lands or her goods. As appeared by inspection she had the face and countenance of an idiot" (10).
Two centuries later the court of wards employed similar questions with measures of numerical ability, which were especially popular. In 1597 German Bradshaw was asked to "number . . . 20 forwards and backwards and divide . . . the same" (11). In 1615 Thomas Pope proved "very well able to discern and know the difference of all pieces of silver of the Queen's coin and the perfect value of them from xiid to an half-penny" (12).
Literacy entered the idiocy testbattery in the seventeenth century. In November 1626 Katherine Tothill was asked "whether she could read or had books read to her. She said she could and did read ... the Bible, all but the hard names." A Bible was produced and Katherine was "bade [to] turn to the Acts of the Apostles, she turned to the New Testament, and turning divers leaves over, she stuck upon a place. We asked her what that was. She answered, 'to the Romans' . . . . which [was] true" (13). Katherine then read several verses from each Testament.
Having scaled these elementary hurdles, Ambrose Bennett was
questioned about several things for his estate. He [stated] that he had £200 a year annuity or better . . . and a legacy of £2000 ... in ready money ... [The examiner] inquiring how he did employ his estate he said that he paid £120 a year ... for his board and being asked what remained of his £200 annuity he said £80. Then what he did with that, he answered he maintained himself and a man . . . after[wards] [the examiner] told him he was very skillful in his estate. (14)
At lunacy hearings examiners also probed for "defective ... memory and understanding," recognizing that "either by reason of age or some other infirmity" a person might "become so forgetful that he . . . forgot his own name" and "be no more fit than a fool or an idiot" (15). However, equal emphasis was placed on behavior. Allegations about William Copley's lunacy were dismissed in 1575 because he proved to be a "sensible man and of good memory and of sufficient discretion to all outward appearance to governe himself and his land" (16). William Warren was "of civil and good and quiet behavior and of good and perfect memory and understanding"; hence, he was no lunatic (17). Similarly, Nicholas Goodridge exhibited "sober and discrete carriage and behavior" (18).
Differential diagnosis was an essential feature of this process. Normal senescence had to be distinguished from dementia, moderate depression from psychotic depression, mild from severe retardation, and knowledge from intelligence. Ann Harecourt was "a woman of 86 years or thereabouts . . . but noe lunatique for shee did answer with as much reason [and] . . . discretion as befitteth a woman of her age" (19). Alice Cutts had "fall[en] into some little discontentment [but] yet [was] not lunatic or distracted" (20). Henry Ridgen was "a simple man [but] no idiot" (21). William Eve was "rudely and ignorantly brought upp But no ydeot" (22). Hence, none of these individuals belonged strictly within the purview of the legal incompetency jurisdiction.
THEORIES OF ETIOLOGY
Notions of etiology focused on biological and psychological factors: physical injury, illness, toxicity, emotional trauma, and social stress. In 1291 a jury ascribed Bartholemew de Sake's mental infirmity to a "blow received on the head" (23). A petitioner explained that Henry Williams had been "visited with extreme sickness being 72 years [old, in 1629] which . . . with want of natural rest has much weakened and debilitated his head . . . so much that he is in great fear of lunacy" (24). According to another petition, John Sykes had long been "greviously visited with a palsey . . . that . . . deprived him of his understanding and of late caused him to fall into lunacy" (25). By contrast, a 1366 jury concluded that Robert Barry's insane violence was "induced by fear of his father" (26). William Burrishe was "put in great fear by thieves breaking into his mother's house in the night" so that he "became distract and speechless most times" (27). In 1623 Elizabeth Gate became "subject to a deep melancholy and discontent . . . by reason of her husband's death and his sale of all his lands . . . the care of her children and want of maintenance" (28).
COURT PROTECTION AND BENEVOLENCE
Whereas mental status tests and etiologic concepts changed little over these centuries, the government's protective role underwent marked expansion both in principle and in its application to English social class structure. According to thirteenth century legal theory, the king (and the private citizens to whom actual guardianship was granted) was entitled to pocket the idiot's estate revenues while keeping him in poverty. On the other hand, a lunatic's profits were preserved until recovery (or saved for the heirs), and the lunatic and his family maintained at their accustomed standard of living (7, 8). These prejudicial terms of idiocy grants were eliminated by 1560, and the court framed both types of grants along the beneficial lines reserved previously for lunatics (29, 30). The king wished thereby "to imitate and approach as near as may be the offices and duties of a natural father" (31).
The case of Benoni Buck dramatically illustrates the government's commitment to this new policy. In 1637 the governor of Virginia conspired to use the estate revenues of an idiot, Benoni Buck, to salary colonial officials. While in the interests of the Jamestown settlement at large, the governor's scheme promised unmitigated exploitation of the idiot's estate. From 5,000 miles away, the attorneys of the court of wards thwarted the governor's ambitions and appointed a proper guardian to protect the idiot's property (32).
The social class composition of cases also broadened over time. From the thirteenth to the fifteenth centuries (23, 33) the legal incompetency jurisdiction strongly favored persons with sizable estates—baronets, knights, and gentry. In contrast, by the sixteenth and seventeenth centuries, roughly 60% of disabled persons were agricultural workers, artisans, and tradesmen—individuals with little or no land and only modest personal property (34-36). In the seventeenth century the court's creation of an informal system of monitored guardianship, shorn of juries and commission hearings, facilitated this change. Court costs were minimized while protection was made accessible to nearly propertyless persons. Thus, a small social welfare dimension emerged, rendered feasible by a "sliding scale" of court fees. In short, a more consistently benevolent jurisdiction was developed that sheltered a wider social class range of English subjects.
Private subjects, usually the petitioner, received custody of the incompetent individual. These guardians supervised the mentally ill, prosecuting suits in the court of wards on their behalf. They defended them and their property against exploitation whether in the form of physical abuse, trespass of property, or opposing legal action (37-39). The court, unable to mandate good will, selected guardians bound to the insane by affection or identity of economic interests. They were to be "the nearest of kin . . . sound in religion, of good governance in their own families, without dissolution, without distemper, no greedy persons, no stepmothers" (31). Whenever possible, the court avoided giving the disabled person over to "the mercy and power of a stranger" (40). The threat of being brought up on charges of abuse of trust by family members and other interested parties, and the relative alacrity with which the court responded to such charges, provided some brake on frank physical or financial abuses by guardians (41, 42).
Occasionally, quite illustrious individuals sought custody of a deranged relative. For example, in 1637 William Harvey petitioned for guardianship of his nephew, William Fowkes, "being an Ideot" (43, 44). Harvey was awarded custody, although apparently a niece had responsibility for Fowkes' daily care. In his will, Dr. Harvey bequeathed money to this niece "for the use and behoof and better ordering of Will Fowkes" (45).
Physical supervision and care of the disabled party were commonly handled by retaining a live-in servant, the so-called "lunatics keeper" (46), a person usually of the same gender as the disabled individual. Hours in attendance and the number of keepers fluctuated with the disabled person's clinical status. In 1599 Jane Nollis' maidservant was needed "more than before because she is more violent and unruly as she grows old"
With or without servants, guardians' lives sometimes became an endless round of reparations for their wards' misconduct. Amy Burton, guardian of Frances Dorrington, expended 60 shillings for "messengers and for hiring of horses for seeking out [Frances, who had] often bene enticed away by evill disposed people," 20 shillings for "redeeming at severall tymes [Frances'] . . . clothes laid out by him to pawne," 15 shillings "for a sow with a pigge . . . which [Frances] killed by setting of doggs on her," and 10 shillings "for keeping [Frances] out of the house of Correction for making a disturbance in the Church in Coleman Street [London] in the tyme of divine service" (49).
Boarding out the lunatic or idiot at a private dwelling, in the company of a servant, was also commonplace; this practice in some respects anticipated the development of private madhouses in the eighteenth century(50). Guardians' accounts recite a litany of the per annum costs of diet, lodging, and washing associated with the lunatic's unkeep in another home (51), together with "wages, meat and drinke for persons" in attendance.
ROLE OF THE MEDICAL PROFESSION
Apart from an incidental appearance as a guardian, what role did physicians play in this jurisdiction? Despite the accepted biological nature of the disorders under consideration, physicians played essentially no role in the certification process itself.They are noted on just two occasions as commissioners participating in incompetency hearings—in 1578 (52) and in 1631. On the latter date Dr. Helkiah Crooke, the medical director of Bethlehem Hospital (Bedlam), and several London aldermen were to certify to the court "what they Conceave of the abillite or disabilitie [of an alleged lunatic] for the governement of himselfe and manageinge of his estate" (53). Whether Crooke was introduced here because of his special expertise is unknown.
Physicians are prominent in these records only as treatment providers. For example, from 1615 to 1635 guardians "disbursed [£100] to physitians, to Surgeons and Apothecaries . . . for many . . . consultations . . . in London and elsewhere" (54) for Richard Corbet's treatment. The physician attending the lunatic Peter Temple received a fixed annual fee; in return he agreed to see Temple whenever necessary (55). Many accounts filed by guardians list such occasional or systematic payments to medical men. Unfortunately, the treatment modalities had decidedly distasteful aspects: "Phisicke, Councell, Blood-letting, and giveing the leaches" (56).
RESIDENTIAL CARE IN PHYSICIANS' HOMES
While domiciliary rather than office visits predominated, some physicians accepted deranged persons into their own home for prolonged treatment and supervision. On July 19, 1631, the court ordered that the guardian of Robert Banckworth "shall take care .. . and cause the said [lunatic] [likely defined as a person with an obvious medical problem or injury S.R.] with . . . convenient speed and privacie . to bee removed . . . to the howse of Mr. Doctor Bartlett to bee with him placed for the recoveye of his health" (57). Four months later, apparently unimpressed with Bartlett's treatment, the court ordered that he "shalbe delivered over to Mr. Dr. Wilson ... to take care of the lunatic and to minister physick unto him for his recovery if it be possible" (58). In 1627 Dorothy Cowper "was placed with Mr. [Dr.] Bennett to be cured of her lunacy . . . Mr. Bennett was a very honest man and one that [was] conscious of what he undertook and for his sufficiency in such cures, practice had approved of him" (59). "Ymmediately upon his entrance into his Lunacie" in 1570, Thomas Starkie was "sente . . . to one Mr. [Dr.] Lacon a man skillful in the Cure of that disease" (60). Some physicians, like John Freeman of Kent, not only enjoyed a reputation in "psychiatry," but were formally licensed to treat the "melancholy and frenzied" (61).
Individuals who proved unmanageable in domestic settings could be sent to Bethlehem Hospital (62). However, Dr. Helkiah Crooke was willing to take on some private cases as well. In the late 1620s the family of Edmund Francklyn, a lunatic, retained Crooke to provide neighbors . . . that Jane is . . . well recovered and has very good use of her understanding and memory and able to dispose of herself, her estate and possessions and has so continued for 3 months and more. And . . . that she .. does behave herself with good modesty and disposition in all her actions. (64)
Her guardianship ceased, and presumably Jane's life returned to normal.
The mentality reflected in these documents, from first petition to final recovery, is strikingly "modern" and surprisingly humane. Mental illness is judged a phenomenon of natural, not supernatural, origin; commissioners seek to measure mental status, not divine possession; and guardians are expected to protect the lands and person of the insane and attend to their daily needs and those of their family. Seeking to avail themselves of psychiatric treatment for their wards, they find physicians willing to accept deranged [ie. lunatics that suffered from injury or disease S.R.] individuals into their own home for the purpose of providing prolonged care. [actually short term care to bring about improvement S.R.]
Created in the first instance to protect propertied individuals, this legal incompetency jurisdiction affords only a partial picture of medieval and early modern theories of mental illness and attitudes toward the insane. Nonetheless, given the social class composition of the cases, these ideas and attitudes were clearly not just the enlightened notions of an educated minority reserved for the landed elite. These historical documents narrow the imagined gulf between modern "progressive" approaches to mental disorder and those of the preindustrial past, thereby contradicting previous orthodox and heretical views of psychiatric history.
Physick, Diet, Clothes, Lodging, washinge ... and two Men Servantes to attend upon [Edmund]. Doctor Crooke came down ... from London ... attended with three men and ... carried [Edmund] to London to the Doctor's own house where he was fairly intreated and well used & carefully provided of a good Lodging and wholsome and good dyet, according the Quality of his person and nature of his Infirmity. (63)
Unfortunately, the historical records provide no further details on the therapeutic regimen.
With or without medical care, recovery was commonplace. Reexaminations for the purpose of possible discharge were held either in the court of wards or in the locality. One example will suffice. Jane Powell, a Welsh woman, was declared a lunatic on October 7, 1597. Eleven months later, several local justices in Cardiff found 9.
as well by view examination and conference with [her] as 10.
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