Introduction

In medieval Serbia, mentally ill persons were treated in monasteries because it was believed that religious medicine had a crucial role in treating various neuropsychiatric diseases. Relics of saints were especially believed to have healing powers [1]. As of the 12th century, scientific medicine started developing under the influence of Byzantine and Western medicine [1]. It was also the time when the first Serbian hospitals were founded in the monasteries of Hilandar, Studenica, and Dečani 1. Even after the Serbian Despotate fell under the rule of the Ottoman Empire, treatment and care for the mentally ill in monasteries were not abandoned [1]. It continued throughout Ottoman rule, but soon after the 1830 Hatt-i Sharif, by which Serbia was recognized as a vassal principality with its autonomous internal government, this practice started diminishing.

First attempt at solving the housing issue for the mentally ill

In the 19th century Serbia, sending mentally ill persons to monasteries, where they were treated by fasting, prayer, and "other known means," was common [2]. However, since monks, being busy doing other chores, could not take care of the patients, mentally ill people would sometimes physically hurt other people, even commit murders. On June 7, 1839, in the monastery of Vujan, a mentally ill person, Jovan Milovanović, from the village of Brđan, killed a servant of the monastery, Aksentije Stojanović, with an axe while he was sleeping [3]. This incident was a motive for imposing certain restrictions on the practice of placing mentally ill people in monasteries. With regard to this, on July 10, 1839, the Ministry of Justice and Education issued the "Circular on people who lack brains, and who come to monasteries and churches for healing, in order to prevent their harmful actions" [3]. In agreement with the Metropolitan of Belgrade, the Ministry decided that these persons, if acting aggressively, could not be placed in a monastery but should, as soon as the prayer was read to them, be sent home. The district court was advised that it should, on its behalf and in agreement with the district government, inform all the people through county officials that every family in which "by ill fate, there are crazy people or people affected by other dangerous diseases" should take all precautions [3]. Hence, every family was supposed to accompany ill persons to a monastery for treatment and prayer and to look after them throughout the whole time, so that they would not harm any member of the monastic fraternity nor the present faithful. The Ministry of Internal Affairs made the regulations of the Circular even more strict by demanding that every householder in whose house a person "is inflicted by insanity" should inform the local government of them and immediately take away any weapons or harmful tools from them [3]. Тhe county and district prefects were obliged to take precautionary measures and instruct the householder as to how to take care of the patient's mental health in order to avoid unwanted consequences [3].

Considering the inconveniences that could be caused to monks by mentally ill people staying in monasteries, and constantly referring to the Circular of July 10, 1839, the Metropolitan allowed mentally ill patients to stay in a monastery only as a final measure and with numerous precautions [4]. In the second half of July in 1839, there was an issue of how to deal with the case of Petar Simić from the village of Ripanj in the Belgrade district, who "in the lack of common sense" cut his brother-in-law Ranko Nedeljković's throat with a knife [4]. The police authorities freed him from guilt and responsibility and sentenced him to two years in the monastery of Kalenić. Based on the testimony of Gavrilo Nedeljković, the abbot of the monastery, Petar had been healthy, sane, harmless, and diligent in doing monastery chores throughout the whole stay. On the way home, since he did not have his passport on him, he was arrested by the Smederevo district authorities and directed to the Belgrade court, where he was in custody at the time when his case was being discussed [4]. On August 12, fearing blood feud by relatives of the murdered man if Petar were sent home, the Ministry of Justice and Education appealed to the Metropolitan to direct the man either to the monastery of Kalenić or Studenica, where "prisons for wretched people can also be found," and where he would earn for food and clothing by doing monastery chores [4]. The Metropolitan thought that it would be most appropriate to send Petar as "a man in a dubious health condition" to a place where he could be constantly guarded, given the fact that it was not possible in a monastery setting. Nonetheless, if there was no other solution, he should be sent to Studenica, as it was quite remote from his place of residence, and "since abbot Gavrilo, today's Archimandrite, vouched for his harmlessness and calmness" [4]. In other words, if a patient had no brothers or any other male relatives who could look after him during his stay in a monastery, the Metropolitan agreed to issue an escort letter for taking the patient to a monastery for treatment only if he was verified to be harmless and calm.

No matter how unwillingly the Metropolitan sent mentally ill patients to monasteries, the problem of their housing was urgent. Namely, sometimes unguarded mental patients posed a risk of spreading contagious diseases. Such was the case of a man named Marko Taslak from Mokra Gora. As the head of the Mokra Gora quarantine informed the Ministry of Internal Affairs on August 11, 1839, Marko "had fantasies in the grip of insanity while wandering across hills and rocks, crossing the Turkish border, and leaving the Cordon" [5]. Since there was an epidemic of a contagious disease in Turkey at that time, upon returning to Serbia, he had to be taken to quarantine, but he could not be kept there "because he wanted to smash all doors and make a great noise". On August 31, after getting an opinion from the State Council, the corresponding ministry ordered the head of the quarantine that, when the quarantine period was over, Marko Taslak be put under arrest by the competent court, until a general statute on this very present issue of stationing mentally ill persons was enacted [5]. Two months later, the Belgrade police asked the same ministry for instructions on how to handle a man named Sima Nerandžić from the village of Ševarice in the district of Šabac, who was a craftsman in Belgrade [6]. He was "out of his mind" and was, therefore, sent to a hospital to see a district physician Florian Birg. However, since he was left in the hospital without supervision, it was necessary to put "the aforementioned delusional person" in the police station [6]. The police, nonetheless, did not have a place for him nor the money for his medication. Hence, on October 14, the Ministry of Internal Affairs decided to send the patient home, but at the same time appealed to Regency to issue a general instruction for acting in similar cases [6].

There was also a possibility of putting a mentally ill person under police supervision without his family knowing it. This happened on October 23, 1839, when the State Council ordered the district court of Jagodina to act upon the case of a former president of the Rudnik district court, Marko Rakić, who started showing signs of mental illness and suicidal tendencies while serving his sentence [7]. Namely, the State Council believed that the patient would recover sooner in the family environment and would not be aware of the supervision [7].

As a result of numerous incidents involving mentally ill people and persistent requests and endeavors to permanently solve the problem of their housing, an official action eventually came on November 24, 1839, in the form of the "Project for housing mentally ill and other unfortunate individuals with contagious diseases, within the monastery of Studenica," drafted by the Ministry of Justice and Education [4]. It consisted of five provisions. This document envisaged the construction of a building affiliated to the monastery, divided into four sections - three for ill people and one for two police officers who would guard them [4]. The cost of the food, clothing, and necessary furniture for the ill, as well as salaries for the police officers, would be paid from the state treasury [4]. The project recommended that, apart from monks who would care for "the wretched," a district physician should come as well in order to "examine the state of their health" and prescribe appropriate medical therapy [4]. All relevant state organs were unanimous in the opinion that placing mentally ill individuals on the property affiliated to the monastery of Studenica was the optimal solution at that time. Although the Ministry of Justice and Education had insisted upon establishing a separate institute at first, it was convinced that there was not enough money for that and accepted the opinion of the majority [4].

The project never came into force because it was strongly opposed by the Metropolitan. After receiving the text for appraisal, in his reply to the Ministry of Justice and Education on December 11, the Metropolitan presented his argument against the suggested way of housing the mentally ill [4]. Expressing his regret that executive authorities did not consult with him before making the draft, he firstly mentioned the practical advantages of building a dwelling for the mentally ill near a town, because then they would be able to easily reach physicians, who were very much needed [4]. The need to place mentally ill people near urban areas was recognized in all European countries since there was no example of these institutions being built on remote monastery properties. Of course, the Metropolitan pointed out that priests would continue to read prayers "to this group of people who suffer," but it did not necessarily mean that they would have to live in a monastery, where their clamor would disturb church service, and scare and offend the faithful [4]. The Metropolitan ended by indicating that founding such an institute which would completely be under the jurisdiction of the executive authority and on the Studenica monastery property, would disturb the internal autonomy of the monastery. The Metropolitan suggested that, in the beginning, mentally ill persons should be taken to monasteries according to the provisions of the Circular of July 10, 1839 [4]. In case that staying in the monastery did not help them, and they proved to be dangerous, the head of the church would recommend that they be placed in an appropriate institution for care and treatment [4]. The Metropolitan's resolute refusal to accept the suggested project of placing persons with mental illnesses in Studenica indefinitely postponed the problem of housing mental patients.

Establishment of the first mental hospital

The problem of housing mentally ill individuals was revived in 1855 when a fund to build a department for the mentally ill within the general town hospital was set up in the state treasury [8]. The department was designed to admit 20 mentally ill persons, who would have their own backyard and a garden and would be isolated from other patients [8]. Until the building was over, the patients were supposed to be placed in barracks in Požarevac, which were adapted for that purpose. However, in the meantime, a garrison unit was moved to those premises, thus the initial plan was dismissed [9]. Competent authorities also considered the possibility of placing the patients in the administration building in Karanovac, but it turned out that the building was on the main street and, therefore, could not be enclosed and used for that purpose [9]. Eventually, at the end of 1860, it was decided to adapt the military warehouse on Vračar – the so-called "Doctor's Tower," and to use it for housing mentally ill patients [10].

On February 6, 1861, the Ministry of Internal Affairs brought a legal project, "The Establishment of Lunatic Asylum," to the State Council for consideration [11]. The State Council made only minor changes in the text. Thus, it can be said that the original form of the document was approved with insignificant changes. The paper was divided into sections in order to make it easier to read. The final version consisted of 37 paragraphs, as opposed to 35 in the original version; they were systematized in seven sections and marked with Cyrillic alphabet letters [11]. As early as February 11, the State Council brought the revised version to Prince Mihailo Obrenović, who authorized it on February 20 and ordered the State Council to print 100 originals and 450 copies of the text and have them brought back to him for signature and confirmation [11]. The State Council did it the next day, and "The Establishment of Lunatic Asylum" was published on March 3, 1861 [12].

"Lunatic Asylum" was situated in the "Doctor's Tower" and was managed by a principal, who was in direct subordination of the minister of internal affairs and took orders and instructions from him [11]. The personnel of this institution was comprised of one physician, one doctor of medicine, who was also the principal, one physician assistant, who had to be at least a "patron of surgery" [11], i.e. an educated physician of the lowest degree in the Habsburg Monarchy [13], one procurement clerk and the necessary number of servers [11]. All of them (except the servers) were appointed by a decree of the prince, according to the suggestion of the Ministry of Internal Affairs [11]. An Orthodox priest was chosen for performing religious duties and was obliged to visit the hospital three times a week, talk to patients, and comfort them, except when the physician estimated that it was counterproductive for the patient's recovery [11].

Paragraph 9 stated that this Asylum was for the treatment of all mentally ill persons, both male and female, adults and children [11]. Given the accommodation capacity and available resources, the corresponding ministry was supposed to decide on the number of mentally ill persons that could be admitted to the Asylum. Wealthier patients would pay for their own stay and treatment. The treatment of poorer patients would be paid for by the state [11]. Modifications of this paragraph from 1873 specified that poorer patients were to be financed through the fund of the general hospital from their hometown district or the district they had lived in lately [14]. According to patients' financial status, they were classified by the line ministry as "paying" and "not paying," based on the opinion of the police authorities of the patient's place of residence [11].

A person could not be placed in the Asylum unless they had been previously categorized as mentally ill by a decree of the competent court (the court of the city of Belgrade) and without the approval of the corresponding ministry [11]. Police authorities were obliged to notify the minister of internal affairs of every unaccountable, mentally ill person who had committed a crime. Police authorities were also obliged to inform the minister of the financial status of the offender and his family, with the purpose of deciding whether they should pay for the wrongdoer's hospital stay [11]. Then, the ministry would issue an order to put the delinquent in the hospital if no family member nor a friend wanted to take care of him. If, however, a family member or a friend offered to look after a mentally ill person, they would have to vow that the ill person would be guarded in such a manner that they "could not jeopardize neither other people's nor their own life, nor be an embarrassment to anyone" [11]. The same would happen if that person came to the Asylum while the patient was still in a "confusional state", except that in this case the approval of the Ministry of Internal Affairs was needed as well. The Ministry's approval was also needed for discharging the patients, who were cured, from the hospital [11].

The physician's main duty was "to take care of mentally ill patients according to laws of medical science, and cure them of confusion as well as any other illness which developed in this state," and he had no right to ask for a special reward for that [11]. As the principal, he was in charge of the internal management of the Asylum, and he was responsible for maintaining law and order, legal usage of medications, and supplying the necessary medical instruments. He had help from the physician assistant, who had to act upon the doctor's orders, and if necessary, be his substitute [11]. A procurement clerk was in charge of supplying the necessary equipment for the Asylum, keeping business records in order, and taking inventory [11].

There was a plan to establish a hospital fund from donations, income from paying patients, money earned from selling deceased patients' possessions, and objects made by patients. The asylum would deposit the raised money to earn interest in the same way as other hospitals did. This fund was for financing "Lunatic Asylum" [11]. The document ended with a short section of only two paragraphs on the procurement of medicines. The provisions stated that the procurement of medications for the hospital should be done by the pharmacy from which the Ministry of Internal Affairs obtained medicines for poorer patients whose treatment was paid for by the state [11]. The asylum was opened soon after its establishment, and the first patient was admitted on August 26, 1861 [15]. All mentally ill people who had been in prisons until the establishment of the Asylum were sent to the hospital for treatment on the basis of the Decree issued on August 8, 1861, by the Ministry of Justice and Education [16].

The head of the Asylum was a physician, i.e. a doctor of medicine [17]. From 1861 to 1865, those physicians were the following: Florian Birg, the Master of Surgery and the second physician of the city of Belgrade, Dr. Vasa Teodorović, previously a quarantine doctor of Aleksinac, and Samuilo Pops, physician assistant (later Dr.) [17]. However, the first physician who was partly more skilled in psychiatry was Dr. Mladen Janković (1830-1885), who was appointed to this position in March 1865. He was soon sent to Vienna for three months in order to get acquainted with contemporary forms of the housing, procedure, and treatment of the mentally ill patients. Upon his return to Serbia, he was to propose amendments to the organization and procedure. With short breaks, he remained in that position, until his death [17].

"The Establishment of Lunatic Asylum" stopped applying on May 1, 1881, when "Law on the organization of the sanitary profession and public healthcare" came into force [18]. This law in 16 paragraphs regulated all important issues regarding mentally ill persons and their hospitalization. "Lunatic Asylum" was renamed "Hospital for Mental Diseases" and divided into two departments [18]. The first general department was designated for treating all mental patients, and the second one was created with the aim of "guarding and caring for incurable delusional patients until their death" [18]. The level of professional qualifications of the hospital principal was raised compared to the previous requirements so that only a psychiatrist, doctor of medicine, could be appointed to the position. Apart from the principal, the physician assistant, procurement clerks, an adequate number of servers, and the auxiliary staff, the hospital personnel also included a secondary doctor, who had to be at least a doctor of medicine and surgery [18]. The minister of internal affairs appointed a special priest for the "Hospital for Mental Diseases" to whom he assigned annual salary. The institute remained under the direct jurisdiction of the minister of internal affairs [18].

Persons who suffer from "all types of mental illnesses, from melancholia to insanity and dementia paralytica" were sent to the hospital [18]. Citizens of foreign countries were admitted to the hospital based on reciprocity with the country whose citizen the patient was [18]. This law also identified two categories of patients - the wealthier, who paid for their own treatment, and the poorer, whose treatment was paid for from the sanitary fund, which was decided by the minister of internal affairs upon receiving the opinions of affiliated municipality and police [18]. Subjected to his exclusive jurisdiction was the decision on hospital admission based on the professional opinion of three doctors who had been observing the patient. If the ill person in question or their family or friends filed a written objection to the hospitalization, the case was resolved by the court. The court also had jurisdiction to classify a person as delusional based on the results of the treatment and move them to another department [18]. The local police authorities were obligated to notify the line minister of all mentally ill people in their area because guarding delusional persons in private homes was not allowed unless their family swore to vouch for their actions and promised to treat them humanly [18]. Patients were discharged from the hospital only with the approval of a special committee formed by the corresponding minister. In order to be discharged from the hospital, a patient had to be completely cured, or, at least, their health had to be improved to the extent that they could not cause harm to anyone any more [18]. Since the hospital was under the direct jurisdiction of the minister of internal affairs, every year he decided which public pharmacy would handle the procurement of medicines for the hospital [18].

Legislation on mentally ill persons

In order to send people with mental disorders to the hospital, it was necessary to legally define the concept of a mentally ill person. It was done in paragraph 40 of the Civil Code of 1844, which stated that persons who completely or partially lacked sanity and free will were "insane, crazy, and delusional" [19]. They were under the special protection of the law because, due to the illness, they were not aware of the harmful consequences of their actions [19]. A commentator of the Civil Code, a notable professor of the Civil and State law at Belgrade Lyceum, Dimitrije Matić, was complimentary about the fact that the legislator had not gone into a more detailed classification of different types of mental disorders, given that it was a matter of disagreement among many doctors and psychologists [19]. Matić pointed out that even the behavior of mentally ill people in the so-called lucid intervals (lucida intervalla) had no legal importance because it would be very difficult to determine what a person incapable of reasoning did in the state of narrowed awareness or moments of full awareness of their actions [19].

Paragraph 53 of the Criminal Code of 1860 excluded criminal responsibility of mentally ill delinquents [20]. In the first edition, this paragraph stated that there was no criminal act if committed by a person who "is not in their right mind," and in the amendment of 1861, it was specified that "there is neither a criminal act nor wrongdoing if a person who committed the act did so while he was crazy" [20]. Such a vague definition, as our famous jurist Đorđe Cenić warned, left some room for the court's subjective judgement on which the offender was considered crazy and, therefore, both unaccountable and criminally irresponsible. All the more so, "people don't call 'crazy' only those persons who are just silly, those who suffer from epilepsy are also put in the same category" [20]. It would thus be good, as Cenić thought, for judges to have at least some basic knowledge about mental disorders. Nevertheless, since these disorders were a matter of disagreement among doctors whose professional opinions, given in proceedings on offenders' mental states, were ultimately contradictory, it would be unrealistic to expect the judges to always be able to evaluate the mental state of a particular offender [20]. Cenić reasoned that it would be better if only "crazy" persons were considered criminally irresponsible than to go into the classification of mental disorders, as it had been done in paragraph 40 of the Civil Code, which only created more confusion [20].

Cenić's concern about courts' subjective judgments on the mental health of offenders proved to be justified, which was evident in two court case records sent to the minister of justice for consideration in 1869 by the Ministry of Internal Affairs [21]. In the first case, the accused of murder was declared crazy and sent to the Asylum, based on the doctor's opinion and hearing of the witnesses. After spending fifteen days in the Asylum, he was found perfectly healthy. Furthermore, it turned out that it was highly disputable whether he had been crazy at the time of committing the murder or whether his insanity was just "a result of his continuous drinking, which is why he got well when alcohol was forbidden for him" [21]. In the second case, a father reported that his son was crazy and socially dangerous, as confirmed by a doctor. The court handling the case declared him crazy without a further evidentiary procedure, but he could not be admitted to the hospital because he showed no symptoms of a mental illness [21]. Taking into consideration all the mentioned above, the minister of justice concluded that the courts had solved these cases very superficially, and in his 1869 Circular, he made an appeal to judicial organs not to easily trust every claim but to examine them with scrutiny [21]. He also addressed the Circular issued on May 14, 1863, by the minister of justice, which advised all courts that, before declaring a person mentally ill, they demand as evidence not only a medical report from a doctor, but also a statement from the local authorities of the municipality the defendant was from, as well as to hear the family and neighbors of the accused [21]. If they still had some doubts concerning the mental state of the offender, they were authorized to demand a second opinion from another doctor and bring the delinquent to court in order to personally discern his mental state [21].

Persons who, due to their mental illness, were not able to take care of themselves and their property were placed under guardianship [19]. A guardian was mostly chosen from the closest relatives and performed this duty, according to paragraph 180, until the reason for guardianship ceased to exist [19]. Guardianship over a mentally ill person was over, in the words of Dimitrije Matić, "when the one who is insane regains sanity" [19]. These provisions ceased to have an effect in 1872 when the "Law on Guardianship" was enacted [22]. The Law became a part of the Civil Code as a separate regulation [22]. The paragraphs concerning adult mentally ill persons were not substantially changed. Since 1872, decisions on guardianship were made by a guardianship judge, who would award guardianship to the spouse or a parent of the person being placed under guardianship [22]. According to paragraph 143, when the guardianship judge was assured that the person who had been placed under guardianship due to a mental illness was cured, based on the court-medical investigation, he would end the guardianship [22]. This meant that the person regained legal capacity at that moment and, thus, the ability to take care of themselves and their property.

Conclusion

With the establishment of the Lunatic Asylum in 1861, the treatment of mentally ill persons in the 19th century Serbia became significantly more humane. Until then, in the absence of an appropriate institution for their housing, ill people who were aggressive and showed suicidal tendencies, and did not have any relatives who would take care of them, were taken to prison. Staying in inhumane conditions without adequate care surely contributed to the deterioration in their mental health in periods when they would become aware of their surroundings and the place they were in. Therefore, the establishment of a special institute for the treatment of the mentally ill helped improve the mental state of those patients, and it was also beneficial for other mentally ill people who received professional medical help in the institution. A step forward was raising the level of professional qualifications of medical staff by the 1881 Law and dividing the hospital into two departments in an attempt to isolate very ill patients. The foundation of the hospital for the mentally ill was performed in compliance with the adequate legislature. Admittedly, it was terminologically imprecise, but it is completely understandable, given the fact that at the time, there were still numerous disagreements even among the experts concerning the diagnosis and classification of mental illnesses. Taking into consideration all the above said, it can be concluded that in the 19th century Serbia a lot was done for mentally ill persons, in terms of providing not only appropriate medical care, but also adequate legal protection for this particularly sensitive and vulnerable category of patients.