A Reappraisal of Psychiatry in the Middle Ages

Jerome Kroll, MD, Orangeburg, NY

Many popular histories of psychiatry accept prejudices equating t takes special courage in the 20th century
the Middle Ages as the Dark Ages and thereby focus unduly on in-
sanity as demonology. They fail to distinguish lay notions and pro-
Ithe witch no
be outspokenly critical and
to contemptuous ot
even
and the
_

baiters and inquisitors of 400

years ago1
fessional approaches of the times, and ignore an unbroken tradition excesses of the Middle Ages. Attitudes toward this period
of medical empiricism.
are usually polarized. There are those who enjoy mediev3
Review of the origins of the Inquisition corrects the notion that it
was established to persecute witches, hysterics, and lunatics. All nat- history and thought; others feel that little worthwhile
ural events were viewed simultaneously as having natural and super- happened from the decline of Rome-around 400 AD-to tl'e
natural significances, and mental illnesses were not singled out from Renaissance-about 1400 ad. The Dark Ages and the
the entire range of private and public misfortunes, ranging from ill- Middle Ages are lumped together and odiously compare
ness, accidents, famines, plagues, and the disasters of war. It was to the splendors of Greece and Rome. There is lamentatio'1
not until the Renaissance and the Enlightenment that the mass that the Church, in its most negative, repressive aspect'
witchburnings and incarceration of the mentally ill occurred. held down the level of culture and achievement. But th
Church had its own critical task of Christianizing the W31"'
like tribes and small nations of Europe, a task which it aC'
complished with remarkable speed and durability.- Afte
all, neither Greece nor Rome were able to reverse the m0'
mentum of their own decadence and deterioration, w"1'
the Church has survived several major crises. Fr°p
roughly 800 to 1000 ad the new civilization in Western
rope was besieged and more than half overrun by t»
BJ£
Saracens, Hungarians, and Scandinavians. Repeated')'
monasteries and communities were pillaged and sacke
Yet by the end of these 200 years, the attackers were coii
verted to Christianity and began to produce a high c"
ture, as evidenced by the graphic arts, architecture, a"
literature of the 12th and 13th centuries. <•
While assimilating the invading hordes to its form °
civilization, the Church was itself influenced by the
of political changes (the emergence of the state), intelle
imP3C_
tual changes (the introduction of Aristotelian and easte
philosophies), and the socioeconomic changes (the beg1 ^

nings of large scale commercial and industrial entet

prises), which frequently were so devastating that
long-promised Armaggedon and millennium were part
the daily consciousness.' .e
If we are to understand the history of madness in <
Middle Ages without distortion-how the disturbed 3^
Accepted for publication April 13, 1973.
From the Rockland State Hospital, Orangeburg, NY.
Reprint requests to Rockland State Hospital, Orangeburg, NY 10962
(Dr.

Kroll).

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 sane segments of the population were treated as stood popular ally. Theology had that vast world of pagan
they
ere, and why, we must put ourselves into the mentality mythology, superstition, mystical traditions, and from the
the people of that time, experience things as they were, time of Crusades, a large influx of astrology and occult sci-
u
the same assumptions and models of conceptual
use ences from the Muslim countries. Empiricism incorporated
Sanization that they would use. Furthermore, we must the Greek scientific tradition, the humoral theory of hu-
our historical facts
straight, and avoid sweeping gen- man physiology in the tradition of Hippocrates and Galen,
erations that ignore the actual differences and changes and the Arabic-Jewish scientific commentaries on Aris-
im-,
Were occurring so dramatically in Europe in the totle.
M'ddle Ages.-» Interestingly, the intermingling of eastern and western
ln-e most
t outstanding feature of these 1,000 years (400 cultures at the time of the Crusades brought to European
400 ad) was the concept of Christian faith. All intellec- civilization support of both its mystical and its empirical
endeavor and most worldly endeavor had to deal with traditions. For the next 300 years (1200 to 1500 ad), the
^central theme.
Church, the propagator of the faith, as was used by,
mysticism-faith-revelation tradition won a hard-fought
(and temporary) victory. This victory was much more ap-
ell as used, the worldly ambitions and activities of
,
parent at the lay level than at the scholastic theological
an^ n°bility, clergy, crusaders, and merchants, and level. The medieval populace accepted its Christianity at a
evi
bid t or ^e Peasant and disenfranchised classes, in their fundamentalist level, infusing it and bending it to its own
t, power.' Christianity was the single dominant pagan traditions and welcoming the rich scope of eastern
°^ ^e Middle Ages, but major intellectual and po-
lit' f
~ecoriom'c battles occurred within this theme; the in-
astrology. Included within this entire nonrational tradi-
tion was the belief in the reality and influence of nonma-
tell
vs K
battle Was that of faith vs reason, or revelation terial beings into the affairs of men. This was translated
cr
servation.
, The political-economic battle, on a con- in Christian terms into angels and devils. If one accepts
stat '' was a power struggle between Church and revelation, then one accepts the daily reality of these spir-
Chr' '-0n an abstract level, it was the struggle between
Ian ascetic values and emerging mercantile values,
its; the earth and its human souls become the battle-
0 , ground for the forces of good and evil.
with battlefields, the Church compromised, at times Conditions of life were harsh and it was easier to see
ctance and bloodshed, at other times with the im- the work of the devil in human affairs than the work of
Petu °
re^orm movements within the orthodox Church, the angels.
For
bodv fmP' e' '-be initialworks
-Aristotelian
response to the influx of the major
at the time of the Crusades
There are several practical implications of a Christian
fundamentalist philosophy. The first is that the devil is
Was ,

a£ain ,Condemn this philosophy. But despite many decrees powerful, operative, and hungry for human souls. The sec-
Thom ,Aristotle from 1200 to 1240, the culmination of St. ond is that the commodity of value is the soul, not the
and
14th
A*-
ristote'ian
"
W°rk in 1273
the synthesis of Christian
philosophy, accepted finally in the mid-
WaS faith body. The soul is eternal, and must not be lost; the body is
transient. It is the soul that differentiates man from
century.M,..7:,,.HM|,R™,. beast, and if a man loses his soul, then there is no obliga-
Was
'
effieial Church position on any particular issue tion to treat him as a man. If one looks upon mental ill-
force ,
Xed, but changed in response to the worldly ness as an illness of the soul, in which the body and the

Sentin n£ upon it and to the internal pressures of dis- devil team together, then radical treatment becomes justi-
ci thegCOncePts and treatment of the mentally
SeSments. What is critical for
understanding
ill (and
an fied, should exorcism and moral treatment fail.
There is a similarity to the Age of Enlightenment, the
these
''be Miriri Ce^1'S themselves changed during the course of 18th century, when the faculty of reason critically sepa-
tian fa,«,e ges)to 'sbethe awareness that
into
the issues of Chris- rated man from beast. If a man lost his reason, as the in-
andu t» incorporated any such concepts sane appeared to do, he was no longer treated as a man,
treatment. but as a beast. The asylums at Bedlam and Saltpetriere
are examples, and perhaps some of our present institu-
ne
Relativity of Systems of Explanation tions. It does not matter whether the critical faculty is
Each ao-p Can use of all
only th °Se sterns of ^or
explanations phenomena soul or reason; should a man lose it, he can no longer be
0ur knowledge and belief available to it. treated as a man. The concern for the salvation of a soul
°nces- w 6°an use Physics, chemistry, and other hard sci- was prevalent not only in regards to the insane, but in re-

systerns fCanexP'anation.
a'S0 social anc* behavioral sciences as
use
The recent antiscientific
gards to all deviant behavior; wickedness and heresy were
far more important déviances than insanity.
ment h move-

avaüabl tagain made astrology and other occult studies The third implication of a Christian fundamentalist phi-
bgious s
tury as .
1°
S°me
s
system of
as a
bave in general
However,
explanation.
not been used in this cen-
re- losophy is that the demarcations between religious experi-
ences (including demonic possession) and psychologically
this
an
reas0Waíí
age Wh1
°*' exPlainin& phenomena. Perhaps it is for
age finds lt difficult to understand
°Ur so
abnormal experiences are not clearly defined. A wide spec-
trum of behavior that would be considered extremely
and belie/11 Cnristian faith integrated into daily life was pathological today was accepted as normal, if possibly pe-
*n the MidHi culiar, ranging from the dancing manias" that affected
A£es, the two major systems available for whole towns in the 14th century (and were supported even
exPlanati0
emPiricism11pWer? Christian theology and Aristotelian
^ach intellectual system had readily under-
•

a
by the townspeople and clergy who were not affected by
it) to the wandering bands of Battuti,''"l"-"',"l""->-1- who

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 roamed the countryside flagellating themselves and invit- only differences of opinion concerned the application of these pr'n'
ing the townspeople to join them; to individual experi- ciples, which varied a great deal according to the degree of Ws'
ences of a mystical or transcendental nature. The critical dorn and honesty and the scientific education of each practitioner-
factor in the public's and the authority's acceptance of The majority of them were probably too ignorant to have a rea
these deviant behaviors was not the bizarre quality of the understanding of astrology; the chances are they did not broi^'"'
cast the fact, but applied blindly the astrological rules published
behavior, but rather the determination of whether the be- many textbooks. In this they were not worse than the modC
havior was in the service of Christ or in the service of Sa- physicians who use their instruments in a purely empirical \Va"
tan. without any real grasp of the methods involved. The point to re'
Thus, it is not true that all deviant behavior, and all in- member is that the most scientific physicians, those who wer
sanity, was viewed as evidence of witchcraft or stemming looked up to by their humbler colleagues, were the main defend^
from diabolic possession. Indeed, the tolerance for deviant of astrological medicine. This was the great tragedy of mediC8
behavior was greater in the Middle Ages than it is now! medicine; not that its scientific armature was small, but that
was awry.""'"M,
Major Emphasis in Psychiatric Histories
The Zilboorg emphasizes the medieval obsession with de'
My disagreement with the discussions of the medieval monology. It is true that the Middle Ages were certain'*'
in the standard works on the history of psychiatry concerned with the workings of God and the devil, but
period was not until the Renaissance that the demonology cr32
is that the chapters are a combination of accuracy and
inaccuracy, not only in the facts presented and omitted became dominant. The Malleus Maleficarum was writte
but more so in the interpretations and general tone in 1484; Leonardo da Vinci was born in 1452. Zilboor»
toward that period. writes as if the Malleus was the only heritage of t"
A recent article by Werman"' discussing the teaching in Middle Ages. ..

medical schools and residency programs of the history of He also brushes aside the noncreative but response
attitudes toward the mentally ill that did exist. For e*
_

psychiatry indicated that the two books most widely used

were Zilboorg's A History of Medical Psychology" and Al- ample, he mentions the Encyclopedia of Bartholom3e.
exander and Selesnick's The History of Psychiatry.'" the Englishman (written 1225-1230), a Franciscan
and professor of theology, which dealt with mental '
mo|J
Zilboorg's prejudices toward the medieval period are es- nesses in terms of natural causes rather than demonol0»-
pecially clear; he presents facts to indicate that reasonable
thought and care were given to the mentally ill, and sub- or other supernatural causation. However, Zilboorg
c^alr-g
sequently makes a sweeping pejorative generalization: that Bartholomaeus was an exception, far ahead °^J;
"psychiatry (by the seventh century) finally became a contemporaries.""""" He ignores the fact that the & ,
study of the ways and means of the devil and his co- cyclopedia was widely used at universities in manuscr'"_
horts.""""'"" Elsewhere Zilboorg writes: (there are 18 manuscripts of it in the Bibliothèque Nat'0
Psychiatric interests were surrendered to the professional ale at Paris, mainly from the late 13th and early 14th ce
hunter of heretics or to the lonely contemplator of the world who
still dared to puzzle about the nature of the human mind. Psychol-
turies), was listed in a catalogue of the books which
medieval booksellers of Paris rented to the students,""
^
,fl
ogy and psychiatry became completely isolated toward the close of first printed in 1470 (the Gutenberg Bible was printed
the 12th Century and actually disappeared as subjects of scientific
consideration.14""2"'
1456) translated into English in 1495, Dutch and Sp3"1*,
These statements are, at best, gross distortions; at
shortly thereafter, and reached more than 20 editions
1500.'»
worst, patently untrue. They are distortions as to facts, Bartholomaeus tried to localize the cause of madnes» ,
significances, interpretations, and historical context. Con- the regions of the brain around the lateral ventricles- ^
sider this statement: "As to psychopathology, the time ter describing the symptoms of mania and melanch"
was ripe for the monk to replace the doctor"""""" (11th Bartholomaeus prescribes as follows:
and 12th centuries). Of course the time was ripe for the ^
The medicines of them (the suffering person) is, that they ,

monk to replace the doctor, but this had nothing to do

with a demonology-dominated attitude toward insanity.
bounde-that they hurt not them selfe and other men. And
suche shall be refreshed and comfortid-and withdrawen l ^
naj^,
Rather it occurred because in the Middle Ages, the univer- cause and mater of drede and besy thoughtes. And they
gladded with instrumentes of Musike-and some deale be <*
muS'ci -
sities and cathedral schools were founded and run by the
Church, and therefore, most of the learned men in all pied. And at the last if purgations and electuaries suffise" n
fields were monks. they shall be holpe and crafte of surgery."""p" m
It is clear that Bartholomaeus was not an exception ^
Furthermore, it is not true that medicine of the Middle was a most respectable and widely read member of o" .e
Ages was totally unscientific and demon-ridden. Science
was a branch of scholastic philosophy, and as such, its ma- the two intellectually dominant orders of the periodi
jor method was deductive reasoning, with inductive rea- Franciscans and Dominicans.""ch""-'"' rpl
soning playing a lesser role."' Medicine, including psychia- Alexander and Selesnick's book follows the
prejudices of Zilboorg. They mention some achieve"1 ,,
genflt?
try, utilized the sciences available to it. Sarton wrote:
The physician of the Middle Ages had no support from other sci-
ences upon which our present progress is based. The only "scien-
of the period and then proceed to a damning
ization or else diminish the achievement by asserting i¡,
ëene^l
tific" guidance available was astrology. Belief in the principles of it was really an accidental remnant from the Greek f
astrology was universal. It would not have occurred to any good tion.
medieval physician to question these principles any more than to a For example:
modern one to doubt the indications of a good thermometer. The $ .

Furthermore, the physical care of the insane was better '

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 y Middle Ages than it was during the 17th and 18th Centuries. esting that George Sarton, who found a great deal to write about
e of the earliest asylums for the mentally ill, the Bethlehem medicine in his large two-volume Introduction to the History of
1
P'tal in London, was originally far different from the snake Science, commented that advances in surgery, under the impetus
that later became known as Bedlam. In those early days pa- of the casualities caused by the Crusades, were a major medical
ts were treated with much concern. When achievement of the Middle Ages.""""5") For over a thousand years
e the
they were able to
hospital in the care of their relatives, they were given the mentally ill were again regarded as possessed by the devil and
if Hi eir &es to wear so that they could be returned to the hospital
. by evil spirits, or were considered to be witches or sorcerers who
... symptoms should recur. These patients received so much could produce the illness in others."""""
ntion and sympathy from their community that vagrants Brief passages from books by Schneck2" and Veith,21
n
counterfeited badges so they would be taken for former pa- again demonstrate the biases of most authors. As a mat-
lle^ of Bethlehem."-"-"
these more or less isolated examples of enlightened rational
ter of fact, the only two works which deal without prej-
udice to the Middle Ages are George Rosen's Madness in
cont'-'butions.
es were but
carry°vers from the past and not original
from Greek tradition.151"52' Society" and George Mora's chapter on the history of psy-
They came
elsewhere these authors write: "The psychiatry of chiatry in Freedman and Kaplan's Comprehensive Text-
th book of Psychiatry."
Middle Ages can be scarcely distinguished from
Clent'nc demonology, and mental treatment was
Schneck states the following:
sv The field of medicine concerned with mental illness gradually
Wh-ym°US With exorcism.'"'"""»
* wou'd not argue that the ancient Greeks in gen-
was taken over by the priest. More and more as the years passed,
eral demonology took hold. Its influence was powerful and fright-
exniWei>e
natory
more naturalistic and less superstitious in their
systems than the medieval Europeans, never-
ful.2'""2"1
Ilza Veith, in Hysteria, the History of a Disease, states
thel ess,
the uncritical adulation of everything Greek leads that as the theological approach gained ascendency in the
to
jn Very unbalanced view of history. Consider the follow- Middle Ages:
ed
larv ^e
Sptement
perimental
by L- Th°rndike in his A History of Magic
Science.'""-'" "One remarkable corol-
. hysteria ceased to be a disease-it became the visible token
of bewitchment and thus fell within the domain of the Church, the
. .

•hov so-called Italian Renaissance or Humanistic Inquisition, and even the temporal powers, since penalties were
rnent at the close of the Middle Ages with its too ex- inflicted by the lay arm. With the exception of the few who were
dus' ^ fortunate enough to come into medical hands, hysterics became
tbe t*3
atl^e
rification of ancient Greece and Rome has been victims of the witch craze, that long and dreadful mass delusion
allv f 6e n°ti°n that the ancient Hellenes were unusu- that held Europe in its sway for many centuries and constituted
Peonl ^r°m magic compared with other periods and one of the darkest chapters in history.2""™'
'mm S- w°uld have been too much to claim any such Veith goes on to say that Charlemagne (768-814) ini-
^or tne primitive Romans, whose entire religion banished and then declared the death penalty for
was
'^lna"y
•
•

little else than magic and whose daily life,

tially
Publi a those practicing black magic, and that as a result of this,
ser Private, was hedged in by superstitious ob-
for centuries thousands of innocent persons were accused,
risen ^
anc^ ^ears- But they, too, were supposed to have
tortured, and murdered on the charge of witchcraft.
more
in th
a^?r
under the influence of Hellenic culture to a
Shtened stage only to relapse again into magic
These statements unjustifiably equate the practitioner
of black magic with the hysteric, distort the historical con-
'nflue nmg empire and Middle Ages under oriental text in which the Carolingian law operated, and advance
the H li6 ^u^ ^° return to the supposed immunity of
' '

the Inquisition by 400 years, thus making it appear as if

Carrie I ^eS
^rom magic; so far has this hypothesis been
^extual critics have repeatedly rejected pas-
the persecution of witches, a relatively uncommon occur-
sages 11 ater rence from 800 to 1200 ad, was a daily phenomenon.
spUr¡ interpolations or even called entire treatises
George Rosen points out that in the Carolingian period
no °tber reason than that they seemed to
them °° witchcraft was considered a secular offense, not a religious
SUPerstitious
Even s specialized for a reputable classical author,
and recent a student of ancient astrol-
offense, since the practice of witchcraft caused damage to
ogy people's person and property."""" This view is indirectly
this' duK-erStition' and religion as Cumont still clings to supported by Ganshoff,2' who pointed out that Charle-
Helleni .generalization and affirms that "the limpid magne's major concern was for stabilization of his king-
^mus
ulati0n, magic." always turned away from the misty spec- dom by the development of the common law of each na-
s'nce "fu0 But, as I suggested some 16 years tional group under him in order to protect personal safety
the
'dark a
¿le6,. °^ tasticalness
Bellas'
of medieval science was due to and property. Ecclesiastical judgments of a serious or dis-
>?> as well as to the gloom of the puted nature were also brought before Charlemagne's
court and the penalty was usually in terms of payments of
does not^ tory of Psychiatry by Erwin Ackerknecht'"
6 &
fines. As a matter of fact, the law specifically forbade put-
seParate chapter on the Middle Ages. The
chapter °n ,^enaissance ting a man to death without a full trial, and as indicated,
There a m°St psychiatry begins: the death penalty was rarely invoked. The Church, of
Cause we k n°th'ng to say about medieval psychiatry, be- course, could never carry out a death sentence it imposed,
c°ntrast
Va'ue erner
w'tiT acnieveme"ts in other
VGry 'ittle a^ovtt medieval medicine and because in
spheres, little of positive
but would turn the person over to the secular authority.
The books cited here not only ignored the historical con-
contraf
a '"
the the fleld of medicine during the Middle Ages. On
text of the Middle Ages, but have moved history back-
pr°bably nf' 'a^ occurred that was harmful. The worst was
wards, describing events of the 16th and 17th centuries as
bands 0f ba^ inte^ration of medicine. Surgery fell into the
if they occurred during the ninth through 12th centuries.
of
exorcisinr)erf and tneir assistants, psychiatry into the hands
£ Priests and clerical witch hunters.
(It is inter-
...
The implication of much of the literature on medieval

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 psychiatry is that the major preoccupation of the Middle imprisonment before the death sentence, via "relaxation
Ages was witchcraft; that the Inquisition was established, to the secular arm," was inflicted. The accused was give"
almost from the time of Charlemagne, for the primary every chance to repent; only the truly convinced heret'c
purpose of persecuting witches and lunatics. Nothing risked death by fire. To invoke the death sentence was to
could be further from the truth. The Inquisition was es- admit defeat: it was the mission of the Inquisition to save
tablished to combat organized heresy, not witchcraft, and man's immortal soul.
it was only in the 200 years following that the obsessive Much evidence exists to suggest that the Inquisitions
concern with witches and demons slowly came to domi- interest in witchcraft-and its inevitable corollary insan-
nate religious and secular thought. ity—was belated and secondary. Indeed, there is evidence
that the Church traditionally was rather indifferent to the
The Inquisition and the Insane presence of bewitched persons if not bona fide witches
The Inquisition was formally established in 1233 by themselves. In 1080, for example, Pope Gregory VII, in f
Pope Gregory IX as an aftermath of the failure of the Al- letter to Harold the Simple of Denmark, expressed h's
bigensian Crusades to extirpate the Catharist heresy from strong disapproval of "the custom of attributing to priest
southern France. Essentially, the Cathar heresy (Cathari and women all tempests, sickness, and other bodily r"'s'
means "purified") asserted that the material world was fortunes."""7""' Lea goes on to state: "The slight attenti°n
created by Satan and therefore was totally evil. God, how- paid in the 13th century by the Church to a crime so abbot'
ever, having taken pity on mankind, sent His son Jesus to rent as sorcery is proved by the fact that when the Inq"1'
show man how to save his immortal soul from the grasp of sition was organized it was for a considerable time re'
Satan. If the material world is evil, then it follows that strained from jurisdiction over this class of offenses.""".
Jesus was not really a man, and did not really suffer on In 1248 the Council of Valence, while prescribing to 'n'
the cross (his apparent body was an illusion); the cross, quisitors the course to be pursued with heretics, ordere
being material, was evil and must not be venerated. The sorcerers to be delivered to the bishops, to be impriso"e
'

Church has misinterpreted the teachings of Jesus and or otherwise punished.

therefore is built on errors. The Cathars, the purified, In various councils during the next 60 years the matte
would restrict their contact with this world to an irre- of sorcery is alluded to, showing that it was becoming a,
ducible minimum and thus they would be saved. object of increased solicitude, but the penalty threaten0
These Crusades consisted of several invasions, the first is only excommunication.
in 1208, of what is now southern France (then called Even in 1431, despite the political pressures on the 1
Languedoc) by the French nobles from the north, mobi- quisitors by the Burgundians and the English, when J°f
lized by a call from Innocent III. Innocent III resorted to of Arc pleaded guilty of heresy, she was sentenced to 1'
armed intervention only after he was forced to concede imprisonment rather than death. It was only several dav
the failure of his long effort-from 1203 to 1207-to secure later, after she was provoked by her jailers and proba" •

the cooperation of the Languedoc nobility in suppressing reconsidered her own recapitulation, that she relaps
a heresy so widespread in the region that he considered it into heresy and was burned at the stake.""7"" In ot" ^

a major threat to the Church and to words, some 200 years after the establishment of the *
Christianity.
It was in a final attempt to persuade the Cathari to quisition, by which time the distinction between Wi»
relinquish their heresy that St. Dominic (1170 to 1221) had craft and heresy had become blurred, it was still poss'
'
begun his missionary work in Languedoc in 1205; it was for Joan of Arc, hardly an anonymous heretic or sorcC
his failure that had led to the first invasion in 1208. The to have avoided death had she maintained evidence oftr
Dominicans were approved as a mendicant order in 1215, repentence. ,
n
with the main purpose of preaching and teaching the gos- However, asthe 15th century progressed, the quest'
'
pel among infidels and heretics.'""''"" Not until 1233, after of sorcery and witchcraft became increasingly prom¡"e
it was clear that the military defeat of the Albigensians and began to show up in the charges and convictions
(Cathari in the region of Albi in Toulouse) did not sup- the inquisitors. The obsessional preoccupation with w'tc,
press their heresy, did Gregory IX establish the Inquisi- craft was a phenomenon, not of the Middle Ages, but
tion by assigning to the Dominicans the task of rooting the 15th and 16th centuries. It represented an entire s°
^
out heresy. However, the formal organization of the In- ety's reaction to its own religious, ideological, and poli113 j
quisition as a separate, clearly defined institution took disintegration, as the medieval structures of Church
time; the initial stages were barely completed by 1250.2' In
1252, by the bull Ad extirpanda, Innocent IV approved the
State tried to resist the rapid development of
bourgeois economics, and political theory by dealing v/1
sc*efl.th
use of torture to obtain confessions. The Inquisition was all dissent as heresy and demon-inspired witchcraft-
very successful, not only because of the tortures, but be-
cause one of the essential signs of true repentence was to
The Roots of Medieval Medicine
name everyone whom the penitent thought might be ei- Medicine and psychiatry in the Middle Ages coml" ,
ther a heretic or an associate of heretics. two separate traditions, that of academic medicine
The early Inquisition was aimed at heretics, not that of folk medicine. The tradition of academic med'
witches; furthermore, the death penalty was rarely in- f
was, from the fifth to the 10th century, handed down t
voked, since the aims of the Inquisition were penitence master to pupil and after the 12th century, was ta, J»i
and renewed orthodoxy, not deaths. A both in organized medical schools and as part of the 1'
long series of pen-
alties could be imposed, including pilgrimages, fines, and clerical education. This tradition was based on the tr

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 ations of the writings of Hippocrates and Galen, and then According to Galen's physiological psychology, mental
on the late Empire (sixth and seventh centuries) physi- functioning at all levels, including emotions and abnormal
cians such as Alexander of Tralles and Paul of Aeginata. functioning, depended upon the state of health or ill-
During the centuries (eighth to 11th) when Europe was health of the person's physiology, specifically, upon the
esieged by barbarians, and intellectual activities were balance of the body's humors and qualities.27 Galen
reduced to monastic copying of manuscripts and scholastic stressed the importance of the four primary qualities-
^.religious) topics, the continuity of the Greek empirical heat, cold, moisture, dryness-rather than the four hu-
.rad'tion in medicine was maintained in the Arabic-Jew- mors.

jsh
°cus of
centers in
Bagdad, Alexandria, and Moslem Spain. The
activity returned to mainland Europe in the 12th
Imbalance of the humors affected temperament and
caused disease, but this occurred by virtue of the pairs of
nd 13th
century with the works of such men as Bartho- qualities inherent in the humors. Thus, blood had the qual-
¡omaeus of England and Peter of Spain""""""-2'' (Pope John ities "warm and moist," yellow bile "warm and dry," black
•»-I). All of these latter works were based on the physi- bile "cold and dry," and phlegm "cold and moist." The
ogical theories of Galen and were free of concern with equilibrium of the humors, and thereby the primary qual-
emonology. In fact, no major medical work taught at the ities, was affected by many factors: foods, for each food
n'versities prior to the 14th century pays attention to de- had its specific qualities; climate, for each season was
•ttonology.
the
dominated by a humor and a pair of qualities; geographic
tradition of folk medicine was represented by the location, periods of life, occupation, sexual activity, and
substantial infiltration of pagan mythology, Christian rit- many others.
» and time-honored folk remedies into the daily practice Moreover, Galen's physiology went beyond the rough es-
medicine. The Anglo-Saxon Leech-Book of Bald & Cild, timate of four primary qualities.2" Each quality was subdi-
nimitted to manuscript in the 10th century, serves to il- vided into four degrees, and each substance (food, medi-
strate this strange mixture; eg, the bite of a viper is to cine, herb, stone) had a designated degree of each quality
smeared with ear wax while thrice repeating the which would determine its therapeutic use; for example,
ayer of St. John," or "a drink for a fiend-sick man is to the following prescription is extracted from Bernard's
urunk out of a church bell, along with the recitation of Tractatus de urinis:
many prayers."2" Secondly, mint is prescribed, for according to Avicenna, it is hot
it K? medicine was omnipresent, superstitious, and inev-
SinCe a11 medicine of the Middle Ages had limited
and dry in the second degree, and it has the property of strength-
ening the stomach and preventing decay; it soothes phlegmatic
effi.cacy. nausea, strengthens the appetitie. .2«<i""»
Folk medicine was not particularly harmful and . .

ain'y not preoccupied with demonology. People in the Arnold of Villanova, a master of Montpellier from 1290
jyj. to 1300 composed his Aphorismi de Gradibus there; this
and •AgGS readily accepted that one fell ill with demons work attempted to elaborate Galen's mathematical phar-
fe t.SPl nts> Just fell ill with urinary troubles and in-
as one
'°ns, and the treatment of both types of conditions macology. Arnold himself dropped the project as his inter-
VGr^ similar: the use of animal parts and herbs ests shifted to eschatology and religious mysticism. How-
Pi 'V ever, his pupil, Bernard of Gordon, wrote a less technical
an(* Prepared in very
hat a special ways and at desig- treatise, setting rules for simplifying the estimation of
times, along with the proper prayers and rituals,
ental and
spiritual illnesses were attributed as much the qualities and degrees of a simple (as opposed to a com-
erw°rk' pound) medication. Nothing ever came of this attempt;
tiv't y as to overeating, and overindulgence in sexual ac- not only were there inadequate concepts and a lack of
p0 climatic conditions, magic spells, and demonic
ession; once again the treatment combined animal technical operations available for measurement, but even
p the same simple (eg, a herb) would have different de-
gat'S'
le
ks, ritual, and possibly shaving the head, fumi-
£ the pubic area, bleeding the person, or using
,
grees in different climates.
There However, despite the failure of the theory to be produc-
ses e !f were many treatments for the person pos-
affected by evil spirits, but torturing and burn-
or tive of valid experimentation, the medical practitioners of
ing the Middle Ages considered themselves to be empirical. If
naLW?re not regularly among them, until well into and
^
lowi
the 15th
e
century.
cussion of academic medicine will cover the fol-
vulture's liver was used in a compound medication, it was
not by virtue of its occult powers; it was by virtue of its
toPics: first, and briefly, the physiological theories specific qualities and degrees.21""75'"
of
Phas"
ç?f
second'y> a brief review of medical training, em- Medical Education in the Middle
•
Ages
revie1Zlng
perg
What Was tau&ht of mental illness; and lastly, a
° S0me °f
the sparse evidence of how mentally ill Medical education went through three transitions dur-
"l
a pr
e°nsmp the physiological theories of Galen because
actually were treated in the Middle Ages,
asize
ing the course of the Middle Ages. There was a tradition
of lay (nonclerical) physicians dating back to the Os-
fnot0undPet
d
r aPPreciation of them will demonstrate that the
a°f medieval medical
10n
psychology biological,
was
trogothic regime of 6th century Italy. The best of these
physicians, trained at the side of their master or in the in-
schol a
Sense ^u8
erm0n0l 0 gÍ C aL The major weakness of the medieval
not ^at tnev not scientific in the wide
were
tellectual centers in the Arab world, were recognized and
appointed by the royal court. As the monasteries in the
they a° word- but that they were not experimental; 12th and 13th centuries became more dominant in the con-
°ut Di]Chepted the authority of Galen (not Aristotle) with-
smng beyond the limits of this knowledge.
tinuity of culture and education, and as the clergy became
more favorable to natural as opposed to supernatural

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 methods of healing, the centers of medical training gradu- were often treated by exorcism or taken on pilgrimage to
ally shifted to the monasteries and then the cathedral a religious shrine. The hospitals and municipalities cooper-
schools. Many of the populac manuscripts kept and copied ated in this. The Hôtel-Dieu of Paris arranged for insane
in the early medieval monasteries contained chapters on patients to be taken on pilgrimages to the shrine of Saint-
medicine, and all young clerical students were taught the Mathurin de Larchant or to that of Saint Hildevert de
rudiments of medicine.2" Gourney. In addition to the municipal corporations, two
MacKinney-'""'"" points out that it was in the cathedral other agencies provided care for the insane—the hospitals
schools, as the centers of learning shifted there and as the and monasteries. In general, the monasteries provided
mendicant orders vied for university chairs, that medicine care only for their own members, and would call in what-
was recognized as a legitimate subject of ecclesiastical ever type of specialized help was needed."
study. Prominent churchmen and leading intellects, such It is difficult to determine when the early medieval con-
as Gerbert of Rheims and Fulbert of Chartres, were cept of hospice-a place of shelter for pilgrims and sträng'
knowledgeable in medicine and taught it at their schools. ers, changed over or enlarged to include that of hospital^3
There was no tradition of supernatural healing at these place of medical care and treatment for the ill. Saf-
cathedral schools.
There was also a tradition of nonclerical medical educa-
ton"""21'" states that the establishment of large hospita'^
as an act of charity was a Christian idea, possibly adopte0
tion, exemplified best by the medical schools at Salerno from Jewish Community houses for the sick. He dates the
and Montpellier. Emperor Frederick II (1194 to 1250) of earliest hospital back to Constantine the Great (324 to 33'
Sicily promulgated a law governing the practice of medi- AD). It is also known that general hospitals existed in the
cine in his kingdom. It established that a premedical Byzantine and Muslim empires.
course of three years of the seven liberal arts, five years of Nevertheless, it is fairly clear that few actual hospH3's
medical study at Salerno, one year of apprenticeship, and existed prior to the Crusades. For example, the first Ë"'
an examination and licensure shall be prerequisites for glish hospital was established by Archbishop Lanfranc 3
the practice of medicine and surgery. The law further Canterbury about 1084. By 1120 there were 18 hospitals >n
went on to establish the doctor's responsibilities to his pa- England, and in the 12th century there, a total of 166 hos'
tients and the range of fees he might charge.'" pitáis were founded, of which 80 were leper-houses.'"""
Care of the Mentally III
Both the religious fervor that inspired (or accompanied'
the Crusades and the devastating medical problems th3
It is clear that the obsession with demonology, to the in- resulted from such mass pilgrimages led to the establish'
clusion of mentally disturbed persons as proper subjects ment of hospitals and of various religious orders devote
for inquisitional questioning and tortures, was largely a to the care of the sick and injured, such as the Knights °
phenomenon of the Renaissance (late 15th and 16th cen- St. John of Jerusalem (Knights Hospitalers), founded '
turies)." Similarly, the period of mass confinement of the 1099 at the time of the conquest of Jerusalem."""""" "

mentally ill began in the Age of Enlightenment (17th cen- As the population of Europe began to increase in tn
tury and beyond).'2 While the ecclesiastical concern with 11th century, and as the towns became centers of comme,
demonology and supernatural medicine was much less in cial and industrial growth,2 the care of the mentally '
the Middle Ages than is usually appreciated, the concern
of the populace with demons appears to have been consid-
gradually shifted from a family to a community proble^
Hospitals began to include special rooms or facilities""''
'

erably higher. Thus, the historian who emphasizes the in 1326 a Dollhaus (mad house) was erected as part of *>"
'
popular folk remedies and superstitions and minimizes or Georgehospital at Elbing, under the Teutonic Knights! j
ignores the learned teachings of Galen about mental ill-
nesses contained in the treatises and encyclopedias of the
1375 a Tollkiste (mad cell) is mentioned in the
records of Hamburg; in 1385 the Grosse Hospital at
muniErfur_
c'Pat
period is giving a one-sided picture, consistent with his was rebuilt and had a Tollkoben (mad hut) where the i",
own prejudices. sane were locked up; in 1403 the Hospital at St. Mary
The most remarkable thing about these historians is Bethlehem in London had, among its nine inmates, s
that they ignore the significance of a town such as Gheel. men "deprived of reason."
A view of mental illness as demoniacal possession and The earliest hospitals designed specifically to care '
witchcraft, demanding torture and burning alive, is in- the insane were established in Christian Spain.'" The f'r
compatible with the facts: since the 12th century, and was the hospital at Valencia, founded in 1409 under
t
probably before, the townspeople of Gheel have taken into guidance of a priest and sanctioned by Pope Bene" .

their homes and cared for the mentally ill and retarded XIII. A brotherhood was organized to finance the hosp1
persons who were brought to the shrine of St. Dymphna
for cures."
and provide care for the patients. The Zaragoza AsylU()S'
Although Gheel is unique-the life of the town itself was
founded by King Alonzo V of Aragon in 1425 was
for giving good "moral treatment." Mental hospitals w
fa"1"^
^r
organized to care for the mentally ill, most medieval
towns as a corporate body accepted some responsibility
founded in 1436 at Sevilla and Valladolid as acts of
cha1^
by wealthy merchants. The care given to patients in t" g ,

for the mentally ill. Rosen" cites the municipal accounts early asylums was of a much higher quality than atlßP
of Hildesheim from 1384 to 1480 showing expenditures for
82 lunatics. Of these, 43 were expelled. In Nürnberg from
larger state-founded institutions and converted
houses that were established in the 16th and 17th c
1377 to 1397, 37 insane persons were public
charges; 17 of turies/'2
these were transported to other cities. The mentally ill This last section has presented evidence that the Ieve)S

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 °JMiddle
concepts and treatment of the mentally ill in the
Ages consistent with the general cultural and
were
13. Werman D: The teaching of the history of psychiatry. Arch
Gen Psychiatry 26:287-289, 1972.
14. Zilboorg G: A History of Medical Psychology. New York,
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accounted for mental as well as physical illnesses. The 15. Alexander F, Selesnick S: The History of Psychiatry. New
Prevalent belief that the physical world was only the shad- York, Harper & Row Publishers Inc, 1966.
16. De Wulf M: An Introduction to Scholastic Philosophy. New
owy reflection of the real, spiritual world led to the tend- York, Dover Publications Inc, 1956.
ency to interpret all events, whether man made or natu- 17. Thorndike L: A History of Magic and Experimental Science.
New York, MacMillan Co, 1929, vol 2.
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hese events. Mental illnesses were not singled out as 19. Ackerknecht E: A Short History of Psychiatry. New York,
Hafner Publishing Co, 1959.
eing of greater significance than other strange or indi- 20. Schneck J: A History of Psychiatry. Springfield, III, Charles
vidually catastrophic events. C Thomas Publishers, 1960.
21. Veith I: Hysteria, the History of a Disease. Chicago, Univer-
.Similarly, when medical improvements occurred, these sity of Chicago Press, 1965.
hcluded the field of psychiatry; hospitals, medical schools, 22. Freedman A, Kaplan H: Comprehensive Textbook of Psychi-
unicipalities, and folk remedies extended to the men- atry. Baltimore, Williams & Wilkins Co, 1967.
23. Ganshoff F: Frankish Institutions Under Charlemagne.
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Bryce
24. Strayer JR: The Albigensian Crusades. New York, Dial
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