Madness and care in the community: a medieval perspectiveBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7021.1708 (Published 23 December 1995) Cite this as: BMJ 1995;311:1708
- Department of History, University of Sheffield, Sheffield S10 2TN
- Department of Geriatric Medicine, Hope Hospital, Salford M6 8HD
- Correspondence to: Dr D Roffe
Care in the community for insane people today is more a matter of expert provision than communal support. In consequence, although they are no longer confined to hospital, mentally ill people largely remain marginalised in a society that does not have the resources, nor often the inclination, to take responsibility for their care. The experience of insane people in medieval England seems to have been of a different order, as shown by a particularly well documented case dating from 1383. From the late 13th century congenital idiots were protected by law. Care of lunatics, by contrast, was primarily the responsibility of the family. However, where the family could not or was unwilling to provide, provision was made by the crown. Through the instrument of the inquisition, the diagnosis and social circumstances of each case were determined by commissioners in consultation with a local jury and all interested parties, including the subject himself or herself. The best interests of the subject remained a prime concern, and the settlement that was ordained was tried and enforced in law. The process was confined to those with real or personal estate, but it encompassed poor as well as rich and proved, through the close identity of the local community with the process, to be a sophisticated and effective mechanism for maintaining and sustaining insane people. Unlike today, care in the community was a communal activity that ensured a truly public provision for those who could not look after themselves.
On Friday 31 July 1383 commissioners duly empowered by the king summoned Emma de Beston of King's Lynn, Norfolk, to appear before them in the church of St Benedict in Lincoln in order to assess her state of mind. The record of the interrogation that followed is the most detailed account of the methods used to determine insanity that has survived from the Middle Ages.1 Emma's state of mind had first become an issue in 1382 when she was alleged to have disposed of a large part of her possessions while insane. The escheator of Norfolk (an official who administered regalities in the county) was ordered to carry out an inquisition; personally examining her, he found that she had not been an idiot from birth but had been insane for some four years since being deprived of her senses “by the snares of evil spirits” on 1 May 1378. She had no lucid intervals, and the king ordered her lands and goods in King's Lynn to be entrusted in guardianship during her infirmity to Philip Wyth of Lynn, a kinsman who had no hereditary right in the land.2
The decision, however, was challenged. With the mayor of Lynn colluding, the doors of her lodgings were locked against the escheator, and a plea was made to the king protesting her soundness of mind. The case was then adjourned to Chancery, and in her petition Emma claimed that the initial inquisition was suborned by Philip Wyth and unnamed accomplices, who conspired to benefit from a surmise of her idiocy, and she sought her guardianship be granted to 12 townsmen of Lynn who were unrelated to either party. She herself, if responsible for this declaration, does not seem to have contested her incapacity, but the mayor and his fellow townsmen stated that she was not an idiot but of sound mind, knowing good from evil and evil from good, and enjoying lucid intervals. They also claimed that the escheator had not taken a lawful inquisition, for he had not caused Emma to come before him and had not examined her in person. They further hedged their bets by maintaining the mayor and burgesses of Lynn had jurisdiction in cases of idiocy and insanity by virtue of their charter of liberties.
The commissioners at Lincoln were charged with the examination of Emma finally to determine her state of mind. They called her before them and asked her a series of questions. “Being asked in what town she was, she said that she was at Ely. Being asked what day that Friday was, she said that she did not know. 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 and not knowing the names of the others. Being asked whether she had ever had issue by them, she said that she had had a husband with a son, but did not know his name. Being asked how many shillings there were in forty pence, she said she did not know. Being asked whether she would rather have twenty silver groats than forty pence, she said they were of the same value.” The justices examined her in all other ways that they could devise and found 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 from inspection, she had the face and countenance of an idiot.”
As a result of this inquest, a compromise was reached. On 26 October 1384 the custody of Emma herself was entrusted to Philip Wyth, but her lands and possessions were assigned to four burgesses of Lynn. They undertook to give to Philip from the issues of the estate reasonable sums of money for her maintenance and use, as well as clothes, beds, and other necessities, and they were to account for the residue to her if she got well, or in such other way as the law required.2 No further alternations are known to have been made to this settlement, and Emma died, apparently still insane, on 30 December 1386, leaving her estate to her niece Isabel de Reynham.3
Attitudes to insanity in the Middle Ages
In the popular mind the Middle Ages was a period of unreason in which belief in possession was a commonplace, and indeed the perception has coloured many scholarly examinations of insanity in former centuries.4 The reality was at once more complex and prosaic. The case of Emma de Beston would never make the grade as The Exorcist IV, but could probably inspire a few episodes of Brookside. In recent years several studies have shown that commonsense attitudes to insanity were widespread.5 6 7 Classical notions of humoral imbalance were probably never entirely lost in the West, and by the 13th century they had become the standard explanation of a host of psychiatric conditions in medical treatises and encyclopaedias. In England works by Gilbert Anglicus, Bartholomew Anglicus, and Bernard de Gordon, which summarised ancient learning on the subject as it was transmitted through Islamic scholars, were widely known and read by academic doctors and physicians alike. In intractable conditions like epilepsy, spells and incantations were halfheartedly, perhaps at times sarcastically, stipulated, but the recommended treatments were otherwise the typical dietary, herbal, and surgical regimens of classical medicine.
The lay perception of insanity was evidently less pragmatic. The belief in the efficacy of charms, holy wells, and relics in the treatment of physical and mental conditions was a commonplace throughout much of the Middle Ages. But that did not preclude an understanding of mental disorders in somatic terms. Madness consequent to trauma, fever, and the like was widely understood for what it was in 14th century England and subsequently, and there is little reason to believe that a demonological aetiology was ever routinely sought for most conditions other than epilepsy.
Less attention has been paid to the care of insane people. There were few hospitals in the early Middle Ages that specifically cared for mad people; indeed, many charitable foundations explicitly excluded them. Foundations were to be found in London and Chester, but otherwise there was no regular provision in England.8 9 By necessity, care was provided in the community. The involvement of the crown has long been recognised. The origins of the present Court of Protection, which administers the estates of those who are incapable of their own management, can be traced through the Court of Wards to the Chancery incompetency jurisdiction of the later Middle Ages.10 The functions of that jurisdiction, however, were much wider than those of its modern counterpart. The case of Emma de Beston reveals a sophistication that rivals the provisions for care in the community of today.
Emma was clearly incapable of managing her affairs at the time at which she was examined, but the truth of the various allegations of peculation at her expense cannot be determined. Nevertheless, the settlement that was reached hints at a judgment of Solomon; it was evidently founded in a full investigation of Emma and her social circumstances. It was made possible by the instrument of the inquisition. In origin the device was a means by which the crown gathered information from the localities that was not readily available through the usual channels of local government. A jury of freemen and such other people who were likely to have knowledge of the matters under investigation were called before a royal official, and all were required to answer questions put to them under oath.11 The inquisition was a simple and effective fact finding exercise. In the course of time, however, its grounding in the community and independence of local government endowed it with such authority that by the 13th century it had assumed quasi-executive functions.12 It was the combination of community participation and royal authority that made the inquisition a particularly effective instrument in providing for insane people.
Intervention by the crown
The origins of royal jurisdiction in the matter are various. The responsibility of insane people in criminal and civil suits is occasionally addressed in early English law codes and treatises, but guardianship is first discussed in a semi-official tract known as the Praerogativa regis dating from the reign of Edward I (1272-1307).13 This distinguished for the first time between the natural born idiot and the lunatic. The former was incompetent from birth and, with due regard for the rights of the feudal lord, was in the wardship of the king; provision was made for his wellbeing, but the profits of his estates accrued to the crown until they passed to the idiot's heir on his death. The crown's intervention in this area was probably a recent innovation. Fleta, writing somewhat later, circa 1295, states that wardship of congenital idiots was formerly the right of the (feudal) lord, but such idiots had suffered so many disherisons that it had been provided that the king should assume their protection.14 Anecdotal evidence suggests legislation in the later years of the reign of Edward's father, Henry III (1216-72).15
The lunatic, by contrast, became incompetent in the course of his life, and the king was to provide for his maintenance and that of his family without taking profit for himself. No legislative act accounts for this special treatment, and it probably emerged through custom and practice. In feudal law physical incapacity to perform military service after the attainment of majority was not a sufficient cause for the forfeiture of a fee.16 Bracton, writing in the mid-13th century, recognised that lunatics had the right to land acquired when sane,17 and it thus seems likely that the fact of insanity had never sanctioned the intrusion of a lord into the estate of a vassal. In the early period it seems to have been purely a matter for the kin,18 as was the directly analogous wardship of sokemen and burgesses,19 and indeed even in the 14th century a family might legitimately make its own arrangements. The involvement of the crown may merely attest the popularity of prerogative procedures to settle all matters of tenure from the late 12th century onwards.
By the late 13th century a procedure, albeit at first informal, had been established. Its outline can be elucidated from the surviving records of some 200 inquisitions in the following two centuries. Natural born idiots came to public notice through the usual process of inquisition post mortem after the death of a holder of land. Lunatics were brought to light either by criminal act or, as in the case of Emma de Beston, by petition of the family or friends. There seems to have been no standard writ to initiate the investigation before the 16th century, but the nature of the jurisdiction required three basic issues to be addressed: was the subject insane, and, if so, from what time, and did he enjoy “lucid intervals”; what lands and chattels were held, and what had been alienated during the period of incapacity; and who was his heir. These questions were put to a jury of local people who were best expected to know the facts, and evidence was also taken from interested parties.
Not the least was the subject himself, and it would seem that no inquisition was valid unless he was interviewed in person. The questions asked of Emma de Beston were carefully tailored to her experience and circumstances: assessment of her general awareness was linked to memory tests, simple skills, and general knowledge. This common sense, pragmatic approach seems to have been the norm. In 1341 Thomas son of Griffin de Grenestede was found to be “of good mind and sound memory in word and deed, counting money, measuring cloth, and doing all things,”3 and several people were able to establish that they were compos mentis in similar diagnostic sessions, apparently in the face of local pressures to prove otherwise.
Once incapacity was established, the settlement ordained was dictated by the nature of the condition. Where the subject was a natural born idiot there was no constraint on the wardship. In all cases a provision had to be made for maintenance according to the value of the estate, and the terms were often specific: in 1384 detailed arrangements were made for the repair of the buildings of Thomas de Bryt, an idiot, of Monkton Up Wimborne, Dorset.20 But otherwise, provided it was not wasted, the estate could be granted, at a price, to whomsoever the king wished for their profit. Courtiers and ministers were occasionally recipients, but families frequently raised the cash to acquire the keeping of their kinsman's interests. If there was no income above the costs of maintenance, however, the king might forego his profit. The treatment of lunatics was more sensitive. Again maintenance had to be provided for the subject and his family, but surplus income had to be reserved for him until such a time as he regained his reason or it could be passed on to his legitimate heir. From at least the mid-14th century, guardianship was conferred on his nearest friend (propinquior), who stood to inherit nothing from his estate.1 3
Once a settlement was made, usually by Letters Patent, there was no formal oversight of its terms. But its provisions were enforceable in law and an interested party might appeal to Chancery should they be breached. John Roger, son and heir of James Roger and his wife Margery, was an idiot from birth, and the provision of one peck of wheat and one peck of peas per week, a tunic at Christmas, two pairs of boots, two pairs of shoes, and a bed worth two shillings had been charged on the estate for his maintenance. The tenant defaulted, and John's representative went to court in 1374 to enforce the agreement.1 In 1364 and again in 1398 complaints were received that insufficient food and raiment were provided by guardians.1 3 In addition, a subject might apply to court for a restitution of his lands should his insanity have passed or to enforce an agreement when a question had arisen about his state of mind in the course of a transaction.
Despite its informality, the whole procedure was not extraordinary. As with so much else in the Middle Ages, it was rooted in the need to manage land, the primary nexus of medieval society. However, it was not confined to the aristocracy or a landed gentry. Only disturbed people with personal or real estate came within the jurisdiction. Thus, married women (as opposed to single heiresses and widows) are rarely the subject of inquisitions. Margery Kempe, for example, also of King's Lynn and a near contemporary of Emma de Beston, seems to have been cared for by her husband without legal formality.21 22 Otherwise, the procedure was of general application and extended low down in the social hierarchy. It has been estimated that as many as 60% of recorded cases in the 16th century relate to tradesmen, yeomen, and other agricultural workers; 20% involved women, many of whom were poor elderly spinsters. It is impossible to calculate similar statistics for the Middle Ages, but a significant number of cases relate to individuals of humble means, as evidenced by the apparent absence of surplus beyond the needs of maintenance. Emma de Beston's income was assessed at the modest sum of three pounds, six shillings, and eight pence (£3.33), the rent on three tenements in King's Lynn, although her husband Edmund may have been considerably more wealthy.1 23
The instances of idiocy greatly outnumber those of lunacy, and it is possible that less cognisance was taken of a condition that was not of immediate profit to the crown.16 However, all processes of justice and administration turned a penny—one of the greatest sources of income was fines for default of one sort or another—and it is more likely that, in an area in which private arrangement was still legitimate, lunacy was referred to royal jurisdiction only when settlements within the family failed. A feud between in laws, for example, wrecked the provisions made for the maintenance of John de Heton and his family in 1353 and brought the matter to the attention of justices.3 John had become insane at the age of 24, being “insensible to his surroundings, and having a fancy in his head, whereby he remains unconscious of his own personality.” For four years he and his family were cared for by his brother William, but John's wife Margaret then fell out with her brother in law. With the advice of friends, John's assets, consisting largely of sheep, were divided, and Margaret and her oldest son moved to the household of Adam de Hopton. Unfortunately, Margaret's sheep died of murrain; as William refused to provide her with support, she sought a settlement in law.
The jurisdiction may have been an emergency service for lunatics and their families in this way. There was also the added incentive that a public declaration of lunacy precluded any threat of royal intrusion into an estate. But for idiocy the procedure was mandatory. Some measure of its efficacy is provided by the strategies that families used to evade its exigencies. On the most prosaic level concealment must have been the most common; it was apparently a tradition in the family of William Chambernon. William died in 1353 leaving his two daughters, Elizabeth and Katherine, as his heirs. Elizabeth was an idiot and within three days of her father's death she was married to William Polgas, who took the profits of her inheritance, which should have belonged to the king, for 14 years. He had issue by her of Richard, likewise an idiot, and a daughter Margaret. On the death of William Polgas, Elizabeth was again married within two days to John Sergeaux, who enjoyed her estates for 16 years, along with Katherine's moiety, which on her death without issue fell to Elizabeth. Since the idiot Richard stood to inherit the whole fee, a certain John Hurle agreed with John for a sum of money to keep Richard in his custody, and married his sister Margaret. To ensure that she inherited all the lands, he abducted Richard and removed him to a place unknown, and by 1396 it was not known whether he was alive or dead. The whole Byzantine saga was brought to some sort of conclusion when John compounded with the crown for the lands on the death of John Sergeaux in that year.1 2 3
Bad blood will out. Where family structure allowed it, enfeoffment (the grant of a tenement in return for service) was a more effective strategy. With the prospect of an idiot as an heir, a father might enfeoff a friend with all of his estates during his life, with reversion to a second son, and receive in return a grant of the income for his life. The estate would then return to the family on the death of his friend into the hands of the sane son. This device could be used with some success, if not always legally, but it required careful planning. On the death of Benet de Marlcomb in about 1390, Maud, his daughter, was found to be an idiot, and so John Preyng straightaway had a charter fraudulently drawn up in his favour and sealed it with the hand of the deceased. He managed to sell the land, but he could not cover his tracks and he was subsequently discovered.3
Nor did enfeoffment always have the desired effect. Godfrey Dautre's heir Thomas was an idiot, so Godfrey enfeoffed Henry de Seresby, chaplain, in his manor of Elslack, Yorkshire, and Henry gave it back to him for life, with successive remainders to Henry and Richard, Godfrey's second and third sons, and their heirs. Unfortunately, both Henry and Richard died without issue, and Thomas inherited the estate. In consequence of Thomas's idiocy the king took it into his hands in 1378.3
Emma's diagnosis and fate
None of these strategies were open to Emma de Beston and those who sought her guardianship. From the available evidence the nature of her infirmity is not absolutely clear. Neugebauer, in the only discussion of the case, asserts that she was a natural born idiot, seemingly on the ground of the use of the word idiota.7 However, that term was not confined to natural born idiots until the later 15th century, and it is clear from the inquisitions themselves and the terms of the settlement that she was considered a lunatic. The diagnosis of possession by evil spirits of the initial hearing is one of only two of all the known cases that were subject to the crown's incompetency jurisdiction in the Middle Ages. But the reliability of the findings of that inquest is undermined by the suspicion of partiality in the proceedings, and indeed in the rest of the surviving records of her case there is nothing to suggest that anything other than natural causes were suspected. If the sudden onset of the condition is accepted at face value, then the most likely diagnosis is probably dementia consequent to an encephalopathy of viral or environmental origin. However, senile dementia remains a distinct possibility. She was almost certainly elderly (on her death her niece was said to be 60 or more3), and the suddenness of the affliction, if not a pure invention, may have been more perceived than real. In either eventuality, no amicable agreement could be made for an incapacitated widow without any immediate family, and resort to law was inevitable.
In the circumstances the settlement that ensued was remarkably sensitive. It may not have been exactly a dialogue between reason and unreason.24 But by necessity Emma had to be cared for within the community, and the incompetency jurisdiction seems to have brokered a compromise that balanced competing interests to provide for her care. Her case is unusual in the extent of the documentation that survives, but it was not atypical. The insight that the case provides into the system reveals a sophistication that characterised it from the very start. Grounded in consultation with the community through the sworn jury, which was associated with the settlements that were made, the jurisdiction was a powerful instrument for the maintenance and sustenance of insane people.
A worse fate today?
It is doubtful whether Emma would have fared much better today under the terms of the current policies of care in the community. The Mental Health Act 1983 states that the Court of Protection can make provisions for the management of estates, and the assessment of incapacity is undertaken by a doctor. There is no statutory procedure, but guidelines on completing form CP3 (the Court of Protection's certificate of incapacity) provided by the Royal College of Psychiatrists and the British Medical Association emphasise the need to assess competence in everyday tasks and general knowledge—typically, much the same questions that Emma de Beston faced are posed, with emphasis on the need to establish awareness and competence within an appropriate social and cultural context. As in the 14th century, the process is complex. Anecdotal evidence suggests that the extent of the government unpopularity in the late 1980s and early 1990s was such that knowledge of the name of the prime minister was not a good indicator of mental competence at that time. Where incapacity is proved, an order can be made to entrust an estate to a guardian or a trust.
The matter of the subject's care, however, does not come within the court's remit. As is usual for mentally ill people generally, provision is assessed by a case conference in which doctors and professional social workers liaise with the family. Nevertheless, ultimately decisions rest with the experts, and it is not always possible to associate the local community with the settlement reached. Where facilities are not provided or are not sufficiently funded, it is not always possible to provide the optimum care. The fate of the landless idiot or lunatic in medieval England may have been little different from that of mentally ill people who roam the streets today, but most madmen probably had more support in the community than do their modern counterparts.
Research for this paper was undertaken under the auspices of the Sheffield Hundred Rolls Project and thanks are therefore due to the Leverhulme Trust for its generous financial support. We are indebted to Dr Tim Cooper, who first brought the case of Emma de Beston to our attention, and we are also grateful to Dr Robert Baldwin, Professor Edmund King, Professor Roy Porter, and Professor Raymond Tallis for their help and comments. Specific references are available from the authors; all errors of fact or interpretation remain our own responsibility.