Fools and idiots?

Intellectual disability in the Middle Ages

Irina Metzler

• Publisher: Manchester University Press
• Year: 2016
• Print ISBN: 9780719096365
• eBook ISBN: 9781784996185
• Edition: 1
• Topic: History
• Subtopic: European Medieval History
• Index: History

Fools and idiots? is the first book devoted to the cultural history in the pre-modern period of people we now describe as having learning disabilities. Using an interdisciplinary approach, including historical semantics, medicine, natural philosophy and law, Irina Metzler considers a neglected field of social and medical history and makes an original contribution to the problem of a shifting concept such as 'idiocy'. Medieval physicians, lawyers and the schoolmen of the emerging universities wrote the texts which shaped medieval definitions of intellectual ability and its counterpart, disability. In studying such texts, which form part of our contemporary scientific and cultural heritage, we gain a better understanding of which people were considered to be intellectually disabled, and how their participation and inclusion in society differed from the situation today. This book will be required reading for anyone studying or working in disability studies, history of medicine, social history and the history of ideas.

1

PRE-/CONCEPTIONS: PROBLEMS OF
DEFINITION AND HISTORIOGRAPHY

Intellectual disability means a significantly reduced ability to understand new or complex information and to learn and apply new skills (impaired intelligence). This results in a reduced ability to cope independently (impaired social functioning), and begins before adulthood, with a lasting effect on development. Disability depends not only on a child’s health conditions or impairments but also and crucially on the extent to which environmental factors support the child’s full participation and inclusion in society.¹

This is the World Health Organisation’s definition of intellectual disability, which incorporates social and environmental factors, and is one attempt at an inclusive definition of a notoriously ambiguous conceptual category – variously called mental retardation, cognitive disability or, most recently, intellectual disability (ID). The terminology immediately prompts a series of questions. What is ID as applied to the Middle Ages? Would a person whom our modern society diagnoses as autistic have been noticed as someone different from the ‘norm’ back in the Middle Ages? Could one, then, even say that autism existed as an illness in those times? And in more general terms, if we do not have a category or label for an entity such as a disease, does that disease exist? Do these different words (medieval versus modern usage) in actuality express roughly the same underlying ‘true’ or ‘real’ concept? Or do all these different terms mean many, just as different concepts? Are medieval medical texts as concerned with establishing strict biological or psychological categories as modern ones? What cultural factors fed into the generation of statements surrounding mental disability in medieval medical texts; e.g. can we say the development of a forensic process in the medieval judicial system (by questioning people as to their mental capacities) had an impact on the way medical professionals described mental disability? The present volume tries to put some of these modern assumptions to the test against medieval evidence. For this purpose, the conditions defined in modern medical terms as IDs will be the focus of interrogation for their medieval counterparts.

While physical disability in the Middle Ages (c. 500 to c. 1500) has become a rapidly emerging topic for scholarly engagement since the mid-2000s, mental or intellectual disability has not yet been adequately researched. ‘Even the most radical historians have only ever treated “intellectual disability” either as a footnote to the history of mental pathology dominated by mental illness, or of disability dominated by the physical disability.’² In part this lacuna has been due to a lack of interest among both medical and social/cultural historians, but also due to the difficulties of uncovering narratives of ID in medieval sources. Since the medieval fool, for argument’s sake the approximate equivalent of the person with ID, often had lifelong mental limitations and hence no fluctuating changes from sanity to insanity, no recoverance of mental faculties, the fool and the madman might frequently be linked,³ but the overarching interest of historians has been in the more glamorous acquired madness rather than folly or idiocy. Research is also hampered by lack of documentation, especially institutional records, pertaining to ID – unlike the mad, the mentally disabled were rarely locked up. For early modern Britain it has been claimed that the absence of institutions for what was then often called ‘idiocy’ was less about lack of diagnostics or distinction from insanity; ‘It was also a result of prevailing policies towards the disabled, which designated idiots (and other groups deemed to be chronically disabled or ill) as unfit for therapy and incarceration because untreatable and harmless.’⁴

In his study of madness in late medieval English literature, Harper concluded that ‘the tendency of critics to conflate the concepts of madness and folly has led to alarmingly widespread disagreement about the meaning of madness’; all too many historians regarded madness as synonymous with folly, whereas, in fact, a closer look at medieval legal, theological and literary sources demonstrates quite clearly that medieval authorities ‘distinguished madness from folly in all of its forms’, with madness more commonly implying mania or melancholia.⁵ The whole question as to whether mental afflictions are categorised as illnesses or not is of course a crucial one. Mental illness, although now a medical category in the modern Western world, was not always such, and was, and to an arguable extent still is, a social construct, based on social ideas about acceptable and unacceptable social deviance. Even with a modern medical knowledge base, it is not entirely clear whether mental illnesses fall into the category of diseases (which can be remedied by giving medicine) or of problems of individual socialisation and perception, which might be remedied by counselling and therapy.⁶ Even should we successfully untangle folly from madness in medieval sources, we are still left with the fool overshadowing the person with ID. We still know comparatively little about mental disability in the pre-modern past because ‘scholarship has remained so preoccupied with the literary figure of the “fool” and the cultural meanings of “folly”, tending to eschew hard analysis of the social problems of the mentally disabled’.⁷ Unfortunately, for the medieval period, the evidence that would permit such ‘hard analysis’ is elusive, to say the least. The historian’s problems ‘are multiform when it comes to actually identifying the mentally disabled amongst the ranks of all those described as having some sort of mental defect or affliction’.⁸

Medical and psychiatric definitions

The main focus will be on concepts and categories of ID as used in the medieval period. As part of this, the book will highlight the problem of imposing modern definitions of cognitive/intellectual/mental disability onto the past. Hence a few words about modern definitions are in order. It has been claimed that the modern concept of ID, as ‘perceived by cognitive, developmental and educational psychologists and in much everyday thinking’, is defined according to five criteria:

(1) It is a deficit in the ‘intelligence’ specific to humans, defined more or less as an (in)ability to think abstractly. (2) This deficit occurs in the mind, as a natural realm distinct from the body; in this sense it differs from physical or sensory disability. (3) The deficit is incurable and thus defines the person, from birth or an early childhood onset until death; in this sense it differs from mental illness. (4) The people thus identified are a tiny, abnormal minority at the lowest extreme from the norm of intelligence. (This holds true whether or not the norm is measurable, by IQ for example.) (5) The causes of the deficit are natural in a deterministic sense, i.e. ‘nature’ implies ‘necessity’. (This holds true whether or not nurture is perceived to have an influence.)⁹

This stands in contrast to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which since the mid-twentieth century and over successive editions has become a standard reference for clinical practice in the mental health field. This ‘bible’ of modern psychiatry classifies cognitive disorders according to neurodevelopmental and neurocognitive disorders. Neurodevelopmental disorders cover broadly what tend to be called IDs, as well as communication, autism spectrum, attention-deficit/hyperactivity and motor disorders, plus the very modern educationalists’ concept of specific learning disorders relating to reading, writing and mathematics. For the sake of argument, my study focuses on disabilities related to this broad category of neurodevelopmental disorders. The one thing in common, regardless for the moment of the question of how applicable these disorders might be for the medieval period, is that they are all developmental, in other words either congenital or connected to specific developmental stages of infancy, childhood or adolescence – they all manifest before adulthood and then remain with the person for life. In medical language, they are ‘nonprogressive’ (although in some genetic disorders such as Rett syndrome there are periods of worsening followed by stabilisation, and in San Phillipp syndrome progressive worsening of intellectual functions).¹⁰ The two most common and well-known IDs today are autism spectrum disorder (formerly Asperger spectrum) and Down syndrome. In French, Down syndrome is referred to as trisonomie, after the triplication (usually spontaneous) of chromosome 21, which causes the syndrome. Down syndrome is the most common genetic cause of neurodevelopmental disorder, with around one in every 600 live births affected.¹¹ Today, around 50 per cent of infants with Down syndrome are born with ‘significant congenital heart defects’, which require life-saving surgery.¹² That was obviously not available in the past, so it is likely that if similar incidences of heart problems occurred in the past, then at least half of all infants with Down syndrome would have died during infancy. However, turn this statistic around, and it follows that about half of Down syndrome babies do not (and did not in the past) have heart problems, so one can assume that this half of the infants could survive into adulthood. With regard to autism spectrum, it has been observed that making psychiatric distinctions between the phenomenology of autism and the pathologies and behaviours of persons with (severe) ID is very difficult in those people with genetic syndromes of ID, since ‘complex cognitive, communicative, behavioral, emotional, and physical difficulties … may mask or emulate’ autism, but according to ‘a pragmatic perspective, the etiology of the behavior presentation is, arguably, unimportant’¹³ [emphasis added]. Mental retardation can be associated with major chromosomal abnormalities or single-gene disorders such as fragile X and Williams syndromes. But again, the range and categorical diversity is rather stunning, and, interestingly for the medievalist familiar with ‘loose’ categories and nebulous (‘unscientific’) definitions, around two-thirds of the people diagnosed today as having some form of ID cannot be squeezed into any of these scientific or medical categories other than one of a general ‘sub-standard’ level of intelligence.¹⁴ Somehow the inability of modern science and medicine to precisely label and categorise ID, despite the enormous advances since the 1990s, with even monthly developments, in the biological sciences in general and genetics in particular, appears worrying and troublesome to researchers and medical specialists.

All these just-cited conditions fall under what the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5] termed neu-rodevelopmental disorders. In contrast, I will not be discussing neurocognitive disorders, which not only tend to manifest in adulthood, but are due to disease (e.g. Alzheimer’s, Parkinson’s, Huntington’s), intoxication (alcoholism) or traumatic brain injury – these are all conditions that may affect a person much later in life and have a fairly clear causality. There is of course scope for an overlap between neurodevelopmental and neurocognitive disorders: ‘Intellectual disability may result from an acquired insult during the developmental period from, for example, a severe head injury, in which case a neurocognitive disorder also may be diagnosed.’¹⁵ As aetiologies for ID, DSM-5 lists genetic syndromes, congenital metabolic disorders, brain malformations, maternal disease and environmental influences such as alcohol, toxins and teratogens, all of which would have been likely risks during the medieval or any other periods. Similarly, problems during labour could lead to neonatal encephalopathy in all times and places. ‘Postnatal causes include hypoxic ischemic injury, traumatic brain injury, infections, demyelinating disorders, seizure disorders (e.g., infantile spasms), severe and chronic social deprivation, and toxic metabolic syndromes and intoxications (e.g., lead, mercury).’¹⁶ All of these are scenarios that are more than plausible for the medieval period, too. DSM-5 presents a summary argument for the physicality of some IDs, and the reason why it is highly likely, in the absence of evidence to the contrary, that the same kinds of genetic disorders occurred in the Middle Ages, and probably in the same proportions to the rest of the population as in the early twenty-first century. If we assume that humans have been anatomically modern for at least 30,000 years, then surely during the past 1,500 to as recent as 500 years they were equally as ‘modern’ in the anatomical sense. Therefore similar disease and developmental patterns will have been in existence in the Middle Ages. The genetic and physiological causes of ID will have changed little, historically, thus ID cannot simply be dismissed as a purely ‘modern disorder’.

Social constructionism and ID

At this point it is apposite to briefly introduce a philosophical critique, primarily expounded by Hacking, of the preponderance in Western academia to claim that nigh on everything, whether people, objects or ideas, is socially constructed. The question of social constructionism in medical history elicited two important articles by Jordanova and Harley, the latter arousing a lively debate, all in the journal Social History of Medicine.¹⁷ Jordanova argued for the usefulness of social constructionism for medical history, considering the link between cultural history and medical hi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• List of figures
• Series editors’ foreword
• Acknowledgements
• List of abbreviations
• 1 Pre-/conceptions: problems of definition and historiography
• 2 From morio to fool: semantics of intellectual disability
• 3 Cold complexions and moist humors: natural science and intellectual disability
• 4 The infantile and the irrational: mind, soul and intellectual disability
• 5 Non-consenting adults: laws and intellectual disability
• 6 Fools, pets and entertainers: socio-cultural considerations of intellectual disability
• 7 Reconsiderations: rationality, intelligence and human status
• Select bibliography
• Index