This paper is focused on three basic questions: The first concerns when specific disabilities first appeared during human evolution. The second question has to do with causes of disabilities. The third question concerns social responses to people with disabilities. Discussions on each of the issues are presented.
A great deal has been learned in the last 40 years since Kanner (1964) wrote his 2-page history of the dawn of concepts of mental retardation. By the early 1980s, Grmek (1983, e.g., p. 118) mentioned certain syndromes of mental retardation in his general review of illness in ancient Western civilization, and Scheerenberger (1983, pp. 3–16) was able to include the outlines of the current picture, primarily from secondary sources. Goodey (1995, 2001) has covered concepts of mental retardation from classical Greece through the 19th century. In the following article I attempt to bring the literature up to date through a review of what is known about the earliest history of general intellectual disabilities and relevant physical disabilities, primarily from the fields of paleopathology and ancient history.
This review is dominated by three central questions: What disorders were present in prehistoric populations and when did they appear? What were the causes of diseases, and what did these causes tell us about the societies in which these conditions occurred? Third, what was the social status of people with disabilities? I deal with the first two questions in the third and fourth sections of this paper, with a review of relevant paleopathological (archaeological) material. The fifth section also includes evidence from the field of ancient history.
The time spanned in this review is from prior to the evolution of human beings through classical Greece (about 2,500 years before the present, B.P.). This end point was chosen because it represents the dawn of the concepts underlying the formal definition of the modern concept of mental retardation.
Although it is likely that disabilities occurred and that they were recognized in ancient Asia or sub Saharan Africa (the area south of the Sahara Desert), I was able to find few relevant references about them for those regions (see Miles, 1997, and Savithri, 1987, for exceptions). Therefore, the material covered in this article deals mainly with Europe and the Americas. Also neglected in this review is coverage of mental illness because inclusion of that field would expand the last section of this paper unduly. For those interested in the history of mental illness, that aspect of the literature is covered in a monograph by Roccatagliata (1986) and for classical Greece, by Dodds (1963, chapters 3 and 4). The review by Dodds covers only chronic diseases. A good general review of acute diseases and their medical treatment is available in several general histories of medicine (e.g., A. Lloyd & Petrucelli, 1987).
The main points emphasized in this article include, first, the idea that individuals with mental and physical disabilities have been members of society since the emergence of Homo sapiens and probably well before that. Second, the increase and concentration of human populations and the development of agrarian societies brought with them an increase of certain diseases and the appearance of new disabilities. Third, nonhuman primate societies and human groups vary in their response to individuals with serious disabilities. Depending on physical environmental factors and, particularly, on age and cultural factors, people with disabilities may be adulated, cared for, ignored, or rejected. Extended families probably provided compensatory care.
Most of the work in this field has been published in the last 30 years. However, for mental retardation workers, special mention should be made of Warkany's (1959) article on the history of teratology and Edgerton's (1968) cross-cultural survey of mental retardation in modern nonindustrialized societies. Warkany reviewed the history of thinking about malformations back to about 4,000 B.P. The earliest ideas were that malformations could predict the future. The author also covered reviews about causes, including the ideas that mental impressions on the mother and sexual congress with animals or with demons could produce malformations. It contrasts these ancient ideas with the modern science of teratology.
Edgerton's (1968) article provides a conceptual basis for understanding the cross-cultural literature in paleopathology. Archaeologists often use anthropological data to complement their observations on ancient societies. Edgerton's conclusions were highly tentative because the anthropological literature on social aspects of disability in nonindustrial societies was (and still is) meager and highly dispersed. However, in his review, he was able to challenge what he perceived as conventional views of the social status of people with disabilities. He denied that people with severe mental retardation are universally killed, that mild mental retardation is not noticed, that it is not stigmatized, and that it is not a problem for the societies involved. Instead, he emphasized that inter- and intracultural variation is characteristic of the social status of people with mental retardation and disabilities. This variation is partly accounted for by environmental stress, but cultural variations are other important determinants.
There are several recent general introductions to archaeological study of diseases and disabilities (i.e., paleopathology). Brief texts, articles in general encyclopedias, and textbook chapters provide very general introductions. For instance, Mays' (1998) text, Renfrew and Bahn's (2000) advanced introductory text, and one by Larsen (1997) provide general overviews. Especially useful for delving deeper into the field is a compendium of all known syndromes with references to specific articles (Aufderheide & Rodriguez-Martin, 1998). Also useful for this purpose are computerized databases (e.g., PubMed, which at the time of this writing, lists about 1,250 abstracts under the keyword paleopathology). There are not many general reviews of the history of disabilities; that is, after the emergence of civilization. However, Garland (1995) provided an extensive coverage of physical disabilities in ancient Greece and, to some extent, Rome.
More recent sources that might be of particular interest to mental retardation researchers are sections of recent chapters by Berkson (1993) and Braddock and Parish (2001). These researchers emphasize the complex nature of the responses to people with disabilities that have characterized society early in our evolutionary history. These complexities will be dealt with in more detail below.
The study of disability in prehistory and ancient history includes data from physical and cultural sources. The physical measures include mainly studies of abnormalities of bone (e.g., fractures, osteoarthritis, and specific malformations) and teeth (e.g., hypoplasias and developmental measures). Hair is sometimes also available for studies of effects of toxicity. Cultural data include “grave goods” (i.e, objects that are buried with skeletons), art objects depicting disabilities, and ancient written descriptions of disability. Less direct, but widely used, descriptions of epidemiology and anthropology in modern populations complement these more direct data. In general, my main interest in this article is in intellectual disabilities. Physical disabilities may or may not help to understand the emergence of our concepts of intellectual disabilities and are brought out when there are no data on intellectual disabilities or when they are clearly applicable to the main point being explicated.
General sources on methods include contributed chapters to Katzenberg and Saunders' edited volume (2000), in which the authors strongly emphasized methodology; chapters in a text on human osteology by White and Folkens (2000); and a volume on data standards by Buikstra and Ubelaker (1994) that provides excellent photos of bone and tooth abnormalities. The photos are accompanied by explanatory text and applications.
It will come as no surprise to readers to learn that archaeological data about ancient populations are hard to come by, and interpretation of those data often is also difficult. At least as important, bias in sampling of skeletons in burials is very common. In many ancient societies, not everyone was buried after death, and usually the bones only of adults and privileged people may be available (Papadopoulos, 2000, summarized the complex literature on this subject). In numerous societies, burial of many individuals in the same grave was the common practice, and in those cases, bones and teeth from different individuals may become lost; therefore, separate identification of specific skeletons is difficult.
Another source of bias is taphonomy, the natural destruction of biological tissue. One relevant taphonomic factor is the chemical nature of the soil. For instance, acidic soil destroys biological material very rapidly. Another problem is that all or parts of skeletons may disappear due to the action of animals.
These factors militate against reliable and valid estimates of prevalence in a population, not only because the instances of disabilities are probably underestimated, but also because population estimates of the group as a whole are difficult. These and several other sources of error make the science of paleopathology difficult (see Goodman, 1993, Stewart, 1969, and discussion below).
The characteristics of graves, sculptural, and figurative depictions (e.g., Anadiotis, 2000), and written products are the data used to assess the occurrence and social and cultural response to disabilities. Writing developed only 5,500 B.P. and known writings about disabilities did not appear before 4,400 years ago in the Middle East.
Moreover, although morbidity and mortality are higher in children than in adults, not only in modern underdeveloped countries, but also in archaeological material (Goodman & Armelagos, 1989), estimates of age in children are crude. This is especially important when one is interested in rates of development, so the difficulty of assessing age works against any precise estimates of rates of development in any individual. Age in children is usually determined through measures of the length of the long bones of the body (i.e., radius, ulna, tibia, and fibula). More stable than this indirect measure of height is an estimate of the eruption of the teeth. Even this best estimate of age is sometimes problematic in children with developmental delays, however, because the various anatomical measures of age are themselves delayed by the disorganization of growth that is common in people with mental retardation (Brothwell, 1960). It may be possible to correct somewhat for this problem by the assessment of Harris lines (radio opaque lines that are formed in long bones during periods in which physical growth was disrupted). Nevertheless, the precision of physical and behavioral growth rate estimates that is currently possible may never be feasible in archaeological material. Despite these problems with age estimates, it has been possible to develop some data on morbidity over development during the childhood years (e.g., Goodman & Armelagos, 1989).
Perhaps most important, it seems in principle impossible to assess mental retardation directly from archaeological material. As I hope to make clear below, syndromes that include mental retardation as one defining characteristic (e.g., Down syndrome) might ultimately become the subject of serious study. However, because mental retardation is defined by behavior and we do not have samples of behavior from physical archaeological material, there are real limitations to the study of mental retardation from biological data. In particular, instances of mild mental retardation might not be detectable. On the other hand, pictorial and verbal references to disabilities are also part of the archaeological record, and it is from these depictions that the main history of mental retardation in antiquity ultimately will be written. The story for ancient Greece has been sharpened significantly by the work of Garland (1995), Goodey (1992, 1995, 1999, 2001), and Edwards (1996, 1997), but almost all other of the great civilizations need more integrative attention. Therefore, real barriers to development of a picture of disabilities in ancient times are apparent. Nevertheless, much is known, and I now turn to a summary of answers to the three major questions cited at the beginning of this paper.
First Appearance of Disabilities
“It has long been known on the basis of skeletal pathology that man has suffered disease and pain throughout his biological history” (Goldstein, 1969, p. 286). This general statement certainly applies to a variety of conditions, including disabling bone fractures and malformations in nonhuman primates, prehuman hominids, and early Homo sapiens. Nevertheless, finding examples of severely disabling conditions is remarkable, not only because of the general difficulties of archaeological work cited above, but also because of the generally low prevalence of severe disabilities and a higher mortality rate of individuals who suffer from them.
Nevertheless, many examples do exist. Schultz (1956) provided a detailed listing of the occurrence and frequency of diseases, parasites, fractures, osteoarthritis, and teratological conditions found in natural populations of monkeys and apes. Many instances of these conditions were relatively minor, but certainly some of the fractures must have been severely disabling, at least in the period that they were healing. Modern behavioral studies have supported the view that at least some monkeys and apes can survive with severe injuries. Perhaps the most famous of these are the individuals who are members of free-ranging Japanese monkey groups and who have thalidomide-like malformations (Furuya, 1966; Nakamichi, Fujii, & Koyama, 1982). Also, Berkson's (1977) experimental studies of macaque monkeys in natural, free-ranging, and laboratory groups is another example (see below for a more complete description of these studies).
There are fewer data for proto-human hominids. In a popular article Bower (1994) referred to a 400,000-year-old cranium found by Jean-Jacques Hublin that seemed to have an abnormality of fetal origin limiting head and limb movement. Better known are analyses of some Neanderthal skeletons. Neanderthals overlapped with Homo sapiens in Europe from about 100,000 to 30,000 years ago, when Neanderthal became extinct. Straus and Cave (1957) showed that the traditional picture of Neanderthal man as having a bent posture was incorrect because that posture was due to osteoarthritis in an elderly specimen. Osteoarthritis was common in ancient populations and is still prevalent today (e.g., Jurmain, 1990).
Another major find is in a family of Neanderthals, found by Solecki (1957) and first described in detail in a series of papers by Stewart (e.g., Steward, 1958). Several members of the family had major defects. One of them, a 40-year old man (Shanidar I), had suffered injuries in childhood that left his left eye probably blind and his right arm paralyzed. Crubezy and Trinkaus (1992) believe that this individual suffered from vertebral and appendicular degenerative joint lesions that were independent of those defects described by Solecki (1957) and Stewart (1958). This Shanidar Neanderthal has generated much discussion about social care of individuals with disabilities, which will be reviewed below.
Homo sapiens appeared about 150,000 years ago, and the picture of disabilities in the first hundred thousand years does not change in important ways beyond the kinds of disabilities seen in monkeys, apes, and Neanderthal. Between 60,000 and 40,000 years ago, instances of artistic expression emerged (Marschack, 1996). Then, 10,000 years ago, in the Middle East and Europe, life patterns of humans changed from a nomadic hunter–gatherer economy to a settled agrarian life style. These changes began to occur later in Asia and still later in the Western hemisphere. Population levels and life expectancy increased, urbanization began, and writing, technology, and the arts flowered. With these important changes, evidence for conditions associated with mental retardation became more definite. Many of the conditions to be discussed probably existed before 10,000 B.P.; however, as yet, there is no relevant evidence because of the factors that have been listed above (i.e., low incidence, generally high mortality, and difficulty of obtaining any data).
In the period following the shift from hunter– gatherer to agrarian-based societies, instances of conditions associated with mental retardation are found. For example, the measles virus became epidemic, probably because measles requires significant population concentrations to become established. Warkany (1959), and more recently Pangas (2000), summarized the recognition of birth malformations by the Assyro-Babylonian culture of 2,800 B.P. The records indicate that people in this culture believed that these malformations at birth were divine portents of things to come and used these malformations for predicting the future.
Blindness is most frequently mentioned in the writings from the Middle East, perhaps because eye problems were so frequent there. Although mental retardation was not described explicitly prior to about 2,000 B.P., it is likely that cases of at least mild mental retardation have always been part of human history. Almost 2,000 years before the formal concept of mental retardation began emerging, mention of other disabilities in adults was part of law. The Hammurabi Code (about 3,700 B.P.) includes epilepsy (Pritchard, 1958, p. 167). Even before that (about 10,000 B.P.), a person with achondroplastic dwarfism was documented (Frayer, Macchaiarelli, & Mussi, 1988).
In addition to some of these conditions that sometimes are associated with mental retardation, there are others that usually imply mental disability (i.e., there are skeletal conditions and depictions of physical syndromes constituting evidence that the person also had mental retardation). One of these conditions is Down syndrome. Aufderheide and Rodriguez-Martin (1998) described separate reports of two cases, one from Saxon England (about 1200 B.P.) and one in Austria (2,350 B.P.) (see also Brothwell, 1960). Diamandopoulos, Rakatsanis, and Diamantopoulos (1997) presented photographs of a figurine that they believed to be a depiction of a child with features similar to Down syndrome. This figurine was discovered in central Greece and was apparently from the Neolithic period (8,500 to 5,000 B.P.)
Aufderheide and Rodriguez (1998) also summarized the literature presenting skeletal instances of hydrocephaly, microcephaly, and anencephaly; but they found no literature on the paleopathology of cretinism. Richards and Anton (1991) not only presented a case of hydrocephaly from 1,500 to 4,500 B.P., but also reviewed the literature and defined the cranial characteristics. In Australia prior to the arrival of Europeans (about 230 B.P.), there was a case of meningocoele, a condition that is often associated with mental retardation (Webb & Thorne, 1985).
There are many instances of disabilities that are not associated with mental deficit. The most prominent of these are achondroplastic dwarfs, who attained high social position during the early dynasties of ancient Egypt. The most famous of these are Seneb (VIth Dynasty) and Khemhotpe (Jeffreys & Tait, 2000; Sullivan, 2001)
Some of these conditions definitely are associated with genetic abnormalities. Thus, recent advances in molecular biology promise to help answer the question of the origin of these disorders. However, DNA analysis has not yet been applied broadly to the study of the paleopathology of chronic disabilities (Stone, 2000, p. 354 ff.), and a fuller picture of the origin of the genetic disorders awaits such study.
Overall, the answer to the question of when disabilities became evident depends on the disorder. Healed fractures and osteoarthritis probably are part of our evolutionary heritage as far back as nonhuman primates. Conditions associated with mental retardation probably existed well before the shift from hunter–gatherer economies to agrarian-based societies. Nonetheless, rare evidence from skeletal remains, written records, and artistic depictions have been demonstrated only from times after populations increased and societies became more complex.
What caused disabilities, and what did these conditions tell us about the ancient societies? The answer to this question combines what is known from modern epidemiology of diseases together with archaeology of societies. Some studies show the way in which societies change as reflected in the patterns of disability at different times (e.g., Nerlich, Rohrbach, & Zink, 2002). However, the main questions studied have to do with (a) the influence of the transition from hunter–gatherer societies to sedentary, agrarian life and (b) the relative prevalence of certain disorders at different ages and from different social classes.
A major movement within paleopathology during the last 30 years has been a consideration of the influence of the shift from hunter–gatherer to agrarian societies. Beginning about 30 B.P., two principles became apparent and were manifested in a 1982 conference on paleopathology at the origins of agriculture (Cohen & Armelagos, 1984) One of these was the increasing use of multiple measures in the same study. The second was the understanding that indicators of health decline when agriculture first develops.
In the last 20 years, these two principles have been elaborated and their developments summarized in a 2002 conference (e.g., Armelagos & Brown, 2002; Goodman & Martin, 2002). Regression analyses have produced general health indices, perhaps partly because some conditions have generalized effects (Steckel, Sciulli, & Rose, 2002). Also, when a society is exposed to one deficiency condition, it is also subject to others (Goodman, 1998; Goodman & Armelagos, 1989). Regression analyses, which are based on substantial variability between societies (McCaa, 2002; Steckel, Sciulli, & Rose, 2002), have also allowed testing of the relationship between certain environmental variables and fertility or a general health index. For instance, climate or agriculture may not be a significant predictor of health, whereas urbanization may be more highly correlated with it.
Beyond general indices, there has also been interest recently on more specific correlations. Nutritional deprivations show up in various ways in bone material. Familiar examples include rickets (lack of Vitamin D) and scurvy (Vitamin C). However, perhaps the most intensively studied group of conditions in paleopathological research are those associated with the various anemias. Because recent epidemiological research (e.g., Hurtado, Claussen, & Scott, 1999) suggests that anemia is a risk factor for mental retardation independent of several other likely correlated factors, these conditions producing anemia are relevant to the topic of this paper. One of the reasons that anemias are the subject of paleopathological studies is that their effects on the skeleton are obvious and a defining property of the conditions. In the archaeological material, anemia (whether produced by food deprivation, a high parasite load, or other diseases such as malaria) is accompanied by porotic hyperostosis (perhaps with cribria orbitalia). A spongy appearance of the bone of the cranium in frontal and parietal areas, perhaps with similar defects in the eye sockets, characterizes these conditions.
The paleopathological study of nutritional deprivations has been done in the context of the question of the effects of the shift from hunter–gatherer economies to sedentary agrarian existence. The basic question is whether this shift was beneficial. The overall answer to this question is a mixed one. Exemplifying this are two papers on the effects of the transition from a hunter–gatherer society to a sedentary agrarian culture. In the first paper Goodman (1998) summarized research at Dickson Mounds, Illinois. He examined pathology of bones and estimated age of death from skeletons of individuals who had lived during the Woodland (hunter–gatherer–nomadic) period through the Middle Mississippian (sedentary) culture. One might expect that life became easier through that transition. However, the evidence showed the opposite. The agrarian sample not only died at a younger age, but also had a higher rate of fractures and osteoporosis (which probably reflected increased work loads), increased enamel hypoplasias, increased bone infections, and increased porotic hyperostosis, reflecting dietary deficiency conditions. Thus, at least at first, it appears that agrarian culture, which depended largely on maize, was not particularly beneficial.
On the other hand, Hodges (1987) studied a sample from Oaxaca, Mexico, who engaged in either nonintensive or intensive agriculture and showed no health effects, perhaps because both groups continued to maintain a balanced diet by hunting and gathering.
Related studies are concerned with social class. Social class in some societies can be defined archaeologically from, for instance, differential location of graves and the quality of the objects (grave goods) buried in the grave with the person. Goodman (1998) summarized a study by Swartstedt that showed a clear difference in tooth defects from graves of ancient landowners and from indentured slaves from a caste-like society. In his own study, Goodman failed to find a significant relationship between measures of social status and health at Dickson Mounds, perhaps because of a small sample; because social status was defined differently in that society; or, more interestingly, because the society at Dickson Mounds was egalitarian, at least with respect to dietary factors.
There are at least some data indicating that dietary factors were one cause of disease in ancient societies and that disease patterns were one indication of the organization of societies. The general approach of analyzing causes of disease and what they tell us about the organization of society is still very much at the beginning stages but so far is promising.
Social Status and Attitudes Toward People With Disabilities
Historically, attitudes toward people with disabilities have been ambivalent, ranging between positive responses (adulation, caretaking) and negative ones (rejection). This ambivalence is reflected in Edgerton's (1968) review, which is summarized above, and also recognized in animals in the classical statement by Charles Darwin (1871/1952):
That animals sometimes are far from feeling sympathy is too certain; for they will expel a wounded animal from the herd, or gore or worry it to death. This is almost the blackest fact in natural history, unless, indeed, the explanation, which has been suggested, is true, that their instinct or reason leads them to expel an injured companion, lest beasts of prey including man, should be tempted to follow the troop. … Many animals, however, sympathize with each other's distress or danger. This is the case with birds. Captain Stanbury found on salt lake in Utah an old and completely blind pelican that was very fat, and must have been well fed for a long time by his companions. Mr. Blyth, as he informs me, saw Indian crows feeding two or three of their companions, which were blind. (pp. 306–307)
As indicated before, modern studies of macaque monkeys have shown tolerance and caregiving of group members who have severe disabilities. The most extensive of these is a series of studies I did on visually impaired members of groups in three habitats. The first was a natural group on an Island in the Gulf of Siam, which was completely dry during part of the year and contained a large monitor lizard that might have been a predator of baby monkeys. A second group was studied on another island off Puerto Rico that had no predators. This group was fed artificial food, and water was plentiful, but, as a result, the island was very crowded. The third group was housed in group cages in a laboratory. The results were clear. In the natural habitat, the animals with disabilities were given compensatory care when they were babies, but they disappeared at 7 months of age. On the free-ranging island, the disabled animals were given compensatory care by the mother and other members of the group when they were babies but gradually became socially peripheral, although they stayed with their groups for 3 years until they became adults. In the laboratory, it was difficult to tell the difference between the impaired animals and controls. One impaired male even became the dominant male of the group when he was an adult. This study clearly shows variation in treatment of individuals with disabilities and the importance of the environment and of age as determinants, at least in these animals (Berkson, 1970, 1973, 1977).
Of course, there are no direct observations of social response toward individuals with disabilities among protohuman hominids. However, there is an interesting and instructive controversy about them. In the initial papers on the Shanidar I find (see above), nothing was said about social response toward him. However, in later, more popular publications (e.g., Trinkaus, 1983), investigators speculated that the survival of the Shanidar I individual with all of his disabilities must have meant that this Neanderthal was cared for by his group for an extended period.
The issue is met at two levels. One is whether the existence of a severe disability implies that others took care of that individual (see DeGusta, 2002, for a recent example). The second is whether such extended care implies that Neanderthal was capable of feeling compassion.
Dettwyler (1991) dealt primarily with the second of these levels. She presented three case histories of people with severe disabilities, the most recent from 7,500 B.P. and offered five assumptions underlying inferences of compassion: (a) The majority of a population's members are productive most of the time, (b) individuals who do not show skeletal evidence of impairments are not disabled, (c) a person with physical impairment is necessarily nonproductive, (d) survival of disabled individuals is indicative of compassion, and (e) caring for and facilitating the survival of a disabled individual is always the compassionate thing to do. She challenged the necessity of each of these assumptions in turn and concluded that whether or not an individual was “handicapped” cannot be determined from archaeological evidence alone. In other words, she appropriately regards such speculation about mental faculties of prehistoric hominids and man as questionable, at best.
Clear evidence about how people with disabilities were thought about and how they were treated only began to be evident from artistic depictions and writing about 4,500 years ago. In dynastic Egypt at that time, achondroplastic dwarfs were functioning members and even honored members of society. Other people with disabilities may also have been protected, whereas still others who had contagious diseases, such as leprosy and tuberculosis, were separated from society (Jeffreys & Tait, 2000).
The Old Testament, which was put together from several sources 2,700 B.P., focuses on two attitudes. One of these, which has been emphasized recently in the literature (e.g., Olyan, 1998; Stiker, 1999, pp. 25–27), deals with one aspect of cultic practice that proscribed sacrifices by individuals with a disability (Leviticus, 21,16; Samuel II, V, 8). This was one aspect of the more general instruction against sacrificing an animal with any blemish. Whether this requirement reflects a general prejudice against disability is questionable. More likely its restriction is limited to the cultic practice of sacrifices to God. For instance, blind and lame priests could partake in the eating of the sacrificed animal. That negative attitudes existed at the time is probable also because the Old Testament further states in several places a commandment that “you shall not insult the deaf, or place a stumbling block before the blind” (Leviticus 19:14; Deuteronomy 27: 18). That is, one might infer an informal negative attitude from this prominent positive statement; but, most important, these statements also reflect the protective ethic of the time in formal statements.
The New Testament, written about 2,000 years ago, reflects two ideas:
As he passed by, he saw a man blind from his birth. And his disciples asked him, “Rabbi, who sinned, this man or his parents, that he was born blind.” Jesus answered: “It was not that he sinned or his parents, but that the works of God are manifest in him. … As he said this, he spat on the ground and made clay of the spittle, and anointed the man's eyes with the clay, saying to him “Go wash in the pool of Siloam.” … So he went and washed and came back seeing. (John, 9)
The first idea represented is that the sources of disabilities are not sin but represent natural phenomena, which are a manifestation of God's works. The second idea is that miraculous cures are possible, thus expressing the possibility that disabilities might be eliminated (at least through divine intervention).
The Quran, written about 1,400 years ago, likewise fostered a protective tradition. As part of a section assuring the support of orphans, the following is included: “And do not give away your property which Allah has made for you a support to the weak of understanding, and maintain them out of it, and clothe them and speak to them words of honest advice” (Surah IV; Verse 5).
Thus, all of the basic sources of modern Western religions imply the existence of negative attitudes but universally espouse an ethic that intends to protect people with disabilities. On the other hand, no such positive ethic is evident in classical Greece and Rome. The literature about attitudes toward people with physical disabilities from Greece and Rome is fairly extensive. In general, people with physical disabilities were mocked. However, some who had visual impairments might have been regarded as having special talents as poets and seers and were treated like shamans, and lame individuals were apparently economically relatively successful. Ancient Greece even had laws that provided small welfare payments to people with disabilities, especially if their disabilities had been the result of wounds in wars. However, overall, they were cared for by their families or were economically marginal and otherwise socially neglected or rejected (see Garland, 1995, for a much fuller treatment of attitudes toward physical disabilities in this period).
Perhaps the first mention of mental slowness is in Roccatagliata's (1986) general review of psychiatry in ancient times. In one paragraph (p. 85), he briefly suggested what he thought was the idea that an implication of the philosophy of Thales of Miletus (2,700 years B.P) provided. Roccatagliata's view was that Thales believed that brain physiology involved a range in its wetness, which in turn determines the difference between mental retardation and mental illness. Roccatagliata thought that an excessively moist brain might result in mental retardation, while excessive dryness would produce mental illness. Not only would this hypothesis include the observation that mental retardation and mental illness are different, but it might have been the first verbal depiction of mental retardation. However, because it is generally believed that Thales left no writings (Barnes, 1982; Freeman, 1959) and that all we know about him comes from Aristotle's works, written about 200 years after Thales lived, this reference may reflect Roccatagliata's views more than those of Thales. Thus, locating the initial concept of mental retardation as originating with Thales probably is Roccatagliata's error.
Goodey (1995) described slow and fast mental states as underlying the concept of mental retardation and attributes the first statement of this idea to Empedocles and 100 years later to the Hippocratic writings, especially in On Regimen (see below). More definite are general statements made by Plato and his student Aristotle. They had not yet formed the explicit descriptions of intellectual disability that we have today, but their views about cognition may have provided the basis for the later development of the modern concept of mental retardation. Stainton (2001) did provide two quotations about “brutishness” from Aristotle's Nichomachean Ethics that might be construed as including mental retardation. However, Aristotle's examples of brutishness (Nichomachean Ethics, 1048b, 25–30) seem to refer to mental illness or characteristic of the minds of people from other cultures rather than mental retardation. Likewise, Aristotle's discussion of natural slaves does not mention people with intellectual disabilities (Vide Supra Politics, Book I, Chapter 4, 1054b; see also Goodey, 1999).
Perhaps Plato comes closest in his definition of simple “ignorance.” However, the Greek for his concept is generally translated as “taking things at face value.” With this concept, Plato does not differentiate between naiveté, lack of opportunity to learn, and lack of ability to think (or, indeed, the effects of congenital deafness).
Therefore, it seems that although general concepts in Plato and Aristotle may form the basis for later concepts of intellectual disability, neither of these philosophers provided a definite description of the concept of mental retardation as we know it today. Goodey (1992) put it most explicitly: “There is in fact no candidate in Plato—or, incidentally, in Aristotle—that measures up to the modern notion of a single unitary and purely human intelligence on a hierarchical scale” (p. 29). On the other hand, it is clear from their writings that Plato and Aristotle both valued honest rational thinking as the defining characteristic of the best in humanity. By implication, they saw individuals who were not wise (i.e., rational and/or moral) as lower in value. Therefore, it can fairly be said that they started a general way of thinking about intellectual ability and, thus, disabilities (see Goodey, 1999, and Stainton, 2001, for fuller accounts of this position).
Looking beyond Plato and Aristotle, one might think that there was a naming of specific types of intellectual disability in the corpus of writings attributed to Hippocrates and his followers (G. Lloyd, 1978). One possibility might be in The Sacred Disease, a description of epilepsy, which not only attacks the concept of the special divine source of the condition but also attempts to describe its locus in the body, with the Hippocratic account of its physiological mechanism. This part of the Hippocratic writings locates the source of madness in an excessive moisture of the brain and asserts that the brain, rather than the diaphragm or the heart, is the interpreter of consciousness and comprehension:
And by this same organ [the brain] we become mad and delirious, and fears and terrors assail us, some by night, and some by day, and dreams and untimely wanderings, and cares that are not suitable, and ignorance of present circumstances, desuetude, and unskillfulness. All these things we endure from the brain, when it is not healthy, but is more hot, more cold, more moist, or more dry than natural. (Adams, 1939, p. 358)
Although the authors of the Hippocratic writings attempt to explain the mechanism of the loss of consciousness and of the temporary loss of memory after an attack, there is no real mention of the chronic general intellectual disability that sometimes is a correlate of epilepsy. In The Seed and The Nature of the Child, the Hippocratic treatises on embryology, there is passing reference to malformations (e.g., G. Lloyd, 1978, p. 323), but, again, there is no reference to mental retardation or its specific levels and forms. In On Regimen there is a description of slow and fast mental states (see Goodey, 1995, above), but this seems to be a description of temporary rather than chronic traits.
More generally, Garland (1995), in his extensive monograph on attitudes to physical disability, included some questionable instances of severe intellectual disability in Greece and indicated that there is no information on mild intellectual disability. Except for some stories from Herodotus and photos of sculptural depictions of individuals from Roman culture in Egypt that he labeled as “cretins,” he did not present any instances of mental retardation from the literature of Greece. However, his detailed account makes it clear that the situation is quite different with respect to attitudes in late Republican and Imperial ancient Rome when explicit references became clear (Garland, 1995, p. 34).
Why is it that explicit descriptions of general intellectual disability are so rare, whereas blindness, epilepsy, achondroplastic dwarfism, malformations, and other mental and physical disabilities are clearly referred to and described? Perhaps the generally high mortality rate of people with severe and profound mental retardation eliminated them from consideration. Perhaps the fact that one can depict intellectual disability only verbally and not through pictures or sculptures might limit their being mentioned. Maybe, for the few people who could write, intellectual disabilities were recognized but not regarded as important enough to mention.
One major possibility is that intellectual disability had not yet been distinguished from mental illness. However, a more interesting possibility also seems likely. Edwards (1997), in an article on physical disabilities in ancient Greece, made the case that the Greek concept of disabilities is somewhat different from the view that she believes is characteristic of modern Western culture. She proposed the view that “disability” for the Greeks was not an inherent characteristic of the individual. Instead, the idea was that a person might be regarded as deviant if they were “unable” to function in society. One might apply this concept to intellectual disability. If a person was supported by his or her family, could perform simple jobs, or was a slave, he or she would not be regarded as unable, and therefore no special mention would be called for.
There is one final hypothesis that may clarify the few cases that are detectable at birth. They might have been killed. Infanticide has occurred throughout civilized human history for population control, for sexual determination (favoring males), and against disabilities. Although some writers assume that infanticide against neonatally evident disabilities characterized ancient treatment of babies, the existence of severe disabilities in the archaeological and historical record demonstrates that infanticide for cases of disability was not practiced universally (e.g., see Scheerenberger, 1983). Plato and Aristotle espoused some selection against defects. In the Republic, which is Plato's statement of an ideal society, he espoused communal rearing of children, with the proviso that “the children of inferior parents, or any child of the others that is born defective, they'll hide in a secret and unknown place” (Republic, V, 460c, cited in Cooper, 1997, p. 1088). In his Politics, Aristotle expressed the view that there should be
a law that no deformed child shall live, but that on the ground of an excess in the number of children. If the established customs of the state forbid this (for in our state population has a limit), no child is to be exposed, but when couples have children in excess, let abortion be procured before sense and life have begun. (Politics, VII, Chapter 16, 1335b cited in McKeon, 1941, p. 1301)
Thus, Aristotle tied infanticide against deformities to population control. Although infanticide has existed throughout known human history, and perhaps was common in certain societies, it was apparently used for general population control and for sexual selection in favor of males. Whether selection against disabilities that were evident at birth was related to these other reasons is not clear. However, it is known that when it was employed in ancient Greece, its practice was sporadic or evidence is lacking (see Edwards, 1996, for a fuller discussion). In any case, even when it occurred, killing of individuals with disabilities was limited to the neonatal period. Thereafter, rejection or adulation was more common, depending on the disability and the culture.
To conclude this review, a brief statement should also be made about treatments. Although spiritual treatments were in common use in antiquity, medical procedures were also widely employed. Herbs for healing and anesthesia were used. Various forms of surgery were applied. For instance, surgery for removal of cataracts, cauterization of wounds, and suturing wounds were all known in various parts of the world (Haeger, 1988). According to Padula and Friedmann (1987), the oldest surgical procedure, amputation of a limb, was conducted 43,000 years ago, and sophisticated ligature procedures with it were carried out at least 3,500 years ago. The oldest and best studied cranial surgery is trephination. This procedure, at least 7,000 years old, consists of drilling holes in the skull. The procedure was used in various places in Europe as well as Peru and perhaps Chile in the Western hemisphere (Gerszten, Gerszten, & Allison, 1998; Marino & Gonzales-Portillo, 2000; Piek, Lidke, Terberger, von Smekal, & Gaab, 1999). In one survey, at least 5% of skulls and at least a few of the patients survived the surgery. The reason for doing this operation is still obscure, but release of spirits and release of pressure from edema are the main hypotheses.
In addition to surgery, prosthetic devices of various kinds were used. Artificial limbs are known from at least 3,500 years ago and considering that amputation was practiced much earlier, were probably invented before then. In addition, in India of 3,000 years ago, the use of artificial eyes, artificial teeth, as well as artificial legs was recorded (Fliegel & Feuer, 1966)
Thus, as far back in history as we know, attitudes toward people with intellectual and physical disabilities have depended on the values of the culture in which they live, with perhaps a bias in favor of young children after the neonatal period. In general also, informal attitudes have been generally more negative than those espoused in public documents and through medical treatment.
Although the science of paleopathology began almost 150 years ago, the general picture about chronic intellectual and physical disabilities in antiquity was not yet clear when Kanner wrote his history of mental retardation 40 years ago. However, since that time, increasing activity in this branch of archaeology as well as in the study of ancient history has brought the picture into focus. In this survey I have attempted to bring up to date this active field. In the next generation, advances in technology undoubtedly will bring with them further significant insights
Chronic illnesses, such as osteoarthritis, healed fractures, and heavy parasite loads, have probably been part of human evolution since before the development of the hominids. The long-term consequences of some communicable diseases and genetic disorders also may have been with us for a very long time. However, the difficulty of existence and early childhood vulnerability, together with low population levels that separated small populations of people, must have limited the emergence of the communicable diseases that result in chronic disabilities.
Increasing population concentration that ultimately came from the development of a sedentary and agrarian lifestyle allowed the transmission of the bacteria and viruses that are associated with disabilities, including mental retardation. Also, at least temporarily, certain specific nutritional deficiencies associated with high parasite loads and a more limited range of diet also caused some cases. It is at this time also that evidence for certain genetic disorders appeared, perhaps associated with low mortality and inbreeding of populations.
Depictions of physical disabilities and mental illness began in sculptures and written material about 4,500 years ago. These included primarily epilepsy, blindness, lameness, and mental illness. However, notably, although mental retardation undoubtedly existed and although variation in concepts of intelligence was recognized in the writings of Plato and Aristotle, the concept of mental retardation was apparently not made explicit either in formal or informal writings prior to the Imperial Rome.
Why there was such a lag in the emergence of the concept of mental retardation is not clear. Perhaps evidence for mental retardation has not yet appeared. The concept may have been in common use, but may not have been thought to be worth mentioning in formal philosophical or medical writings. Finally, mental retardation may not have been differentiated from mental illness until later in history. In any case, it remains to be determined how the concept of a general intellectual deficit emerged after Classical Greece.
Neglect and rejection of individuals with chronic disabilities have characterized social life since before the evolution of Homo sapiens. At the same time, social responses that compensate for disabilities of group members also are common, especially if the person with disabilities is a young member of the family. In some cultures, older blind or mentally ill people were thought to have special skills or powers of forethought and were treated with honor. When they were competent at tasks needed in the society, these individuals also may have overcome negative views and may have achieved high social status.
Although it has been common to believe that in antiquity babies with disabilities were killed at birth, this has been brought into question recently. In fact, the data are sparse, and proponents of the old interpretation did not consider infanticide for other reasons. Older individuals with disabilities were not killed and were sometimes honored. Medical treatment was common, and a variety of prosthetic devices were in use.
Therefore, it is probable that mental retardation has existed for a very long time, but there has been no evidence for it prior to the emergence of settled agrarian life. Moreover, the modern concept of mental retardation had not emerged in Western civilization until well after the recognition of other disabilities. These conclusions must be guarded, however, because aside from excellent studies of the thought of major Classical Greek philosophers, the literature on concepts about disabilities prior to a couple of hundred years ago is very sparse. Studies of mental retardation and other disabilities in prehistory and in the great civilizations of Sumer, Assyria, Egypt, ancient Greece, Rome, Islam, early Europe (Jewish and Christian), India, and China each would be helpful, if done by researchers equipped to do it.
When these studies are conducted, it is probable that investigators will find that the emergence of our modern concept of mental retardation has been slow indeed. As we have seen from the several classification systems that have come out in the past 50 years, the process of refinement of our perceptions has continued.
NOTE: I thank Lawrence Keeley and Sloan Williams who introduced me to archaeology by permitting me to sit in on their classes. Thanks also to C. F. Goodey, Christopher Keys, Tim Stainton, and Sloan Williams for comments on the manuscript.
Author: Gershon Berkson, PhD, Professor Emeritus, Department of Psychology (MC 285), University of Illinois at Chicago, Behavior Sciences Building, 1007 W. Harrison, Chicago, IL 60607. firstname.lastname@example.org