About the Author
Joel Gold, MD, is Clinical Associate Professor of Psychiatry at the New York University School of Medicine. He is in private practice in Manhattan.
Excerpt. © Reprinted by permission. All rights reserved.
Ian Gold, PhD, is Associate Professor of Philosophy and Psychiatry at McGill University.
Suspicious Minds 1
A SHORT HISTORY OF MADNESS
Delusions are symptoms of a disease known, for most of human history, as madness, descriptions of which go back nearly as far as the written records of human civilization. The Papyrus Ebers, for example, an Egyptian medical text dating from 1550 BC, informs the aspiring physician that maniacal behavior is caused by possession, and five hundred years later the Indian Atharva-Veda reports that madness can be caused by “sin against the gods” or by a demon. A charm is provided to enable the sufferer to be “uncrazed.” Among the curses to be visited on the Israelites who fail to obey the Lord is insanity, and Old Testament madmen—the envious King Saul who raves, or the bestial King Nebuchadnezzar condemned to eat grass for his pride—become deranged for their sins.
Figure 1: Nebuchadnezzar, William Blake, 1795. Tate Gallery, London.
The Babylonians and Mesopotamians understood madness as a punishment from the gods or demonic retribution, and insanity has a divine origin in Greek antiquity as well. When, in Homer’s Odyssey, Penelope is told by her nurse that Odysseus has come back and killed her suitors, she says: “ ‘the gods have made you mad. They have that power, / putting lunacy into the clearest head around.’ ” And, in Euripides’s Bacchae, possessed by Dionysus, Agave rips the head off her own son, Pentheus. Long before even the earliest of these writings, our ancestors left us clues to their theories of madness. Archaeological evidence shows that boring holes in the skull (“trephining” or “trepanning”) to release the devils inside is a practice that dates from at least 5,000 BC. Removing the imagined “stone of madness” by trephination was a medieval medical fantasy (see Figure 2).
Although madness is usually thought of as a disturbance, it has sometimes been conceived of as a gift. Plato, for example, distinguished four forms of madness: that of the prophet, the poet, the mystic, and the lover. The hero who is driven mad by unrequited love is a common trope in medieval literature, and the link between madness and poetry—or creativity more generally—continues to our day.
Figure 2: Extracting the Stone of Madness, Hieronymus Bosch, c. 1475. The painting is a satirical representation of the medieval belief that madness was caused by having a stone in one’s head. © Madrid, Museo Nacional del Prado. Reproduced with permission.
With the coming of Christianity, Greek notions of madness were transfigured but not abandoned. Madness was seen to have its source in sin, in witchcraft, or in a battle between the Holy Ghost and the Devil for the soul of the madman. Although it might occasionally be a sign of holiness—in the Middle Ages in particular—the madman’s loss of reason was thought to render him less like his rational God and was usually taken to be a sign of devilry or possession, as in the case of the Gadarene man healed by Jesus. Belief in possession continues into modern times, of course, and the incantations and charms used in some twentieth-century cultures are little different from those found in the ancient world. Even the familiar belief in the evil eye originates in the notion of possession and was already present in Greek culture.
Although the Greeks had a view of madness as divine, they were also the first to conceive of it as disease. In fact, Greek medicine, like our own, took madness to be a brain disorder. A Hippocratic text, for example, denies the divine origin of epilepsy in favor of a purely biological source, the brain: “from nothing else but thence come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations . . . And by the same organ we become mad and delirious, and fears and terrors assail us.” The cause of madness, the author tells us, is a brain that is too hot or too moist.
Figure 3: Jesus Casting Out Devils, Julius Schnorr von Carolsfeld, 1860.
Greek medicine was founded on the theory of the “humors,” or bodily fluids, each of which performed distinct functions and, when in balance, maintained physical health. Some treatments for disease, therefore, sought to restore humoral equilibrium—by bloodletting, for instance, when an excess of blood was to blame. The cause of mental disturbances was thought to be a substance known as black bile (in Greek: melancholia), though just what the Greeks called by that name remains mysterious. (Some combination of coffee grounds in brown vomit, dark urine, and tarry stool, according to one historian.) Nevertheless, the view persisted for centuries: “the devil rejoices in the humor of black bile” was a medieval adage. Purgatives to expel black bile, as well as washing liquids that stimulated its excretion, were thus the treatment of choice for those suffering from madness. A good diet (low in black bile, of course), exercise, and proper hygiene were also advised.
Alongside the medical treatment of madness, the ancients developed psychological remedies as well. These included dream interpretation and “incubation”—the practice of sleeping at a holy site in order to bring about a dream of divine origin. Philosophy also had its share of recommendations. Plato believed that madness came about by the subordination of reason to the lower parts of the mind and so declared the treatment to be the dialectical method. And the Stoics and Epicureans thought that mental anguish could be overcome by the correct application of philosophical truths, although they did not believe that this early form of talk therapy could cure madness.
Medieval medicine followed the Greek model, in particular that of Galen, the Greek doctor whose views were central to medicine for fifteen hundred years. Before the sixteenth century, however, we find no books devoted exclusively to mental illness. One of the first of these, The Diseases Which Deprive Man of His Reason, was written by Paracelsus (who, before being given the brief moniker, rejoiced in the name Theophrastus Bombastus von Hohenheim) and published in 1567. Robert Burton’s monumental Anatomy of Melancholy, published a few years later in 1621, summarizes the treatments for melancholy known since the Greeks. If bloodletting and purgatives fail, Burton tells us, one can try diet, exercise, herbal remedies, travel, music, or marriage. Eighteenth-century treatments also included rotating and tranquilizer chairs, electric shock, and “ducking”—the practice of firing water at the head. To help evacuation on its way, moxibustion, cauterization, and blistering could also be used, but more useful perhaps was the available pharmacopeia, which included opium, henbane, belladonna, and camphor.
The great nineteenth-century psychologist Hermann Ebbinghaus famously said that “psychology has a long past, yet its real history is short.” The same could be said about psychiatry. Human beings have probably wondered about madness ever since they could wonder about anything, but psychiatry as a profession is just over two hundred years old. It came into existence as the medical specialty devoted to treating the madmen that society had locked away.
Although we know very little about the history of attitudes toward the mad, those who were not looked after by their families probably lived wretched lives. Some would have been forced to wander from town to town or be housed in churches which, unlike domestic buildings, could stand up to violent behavior. Still, madmen were not always treated inhumanely. While medieval Christian law, for example, deprived the mad of their rights to be married or ordained, it did permit baptism and communion.
During the Middle Ages religious institutions began the charitable work of housing those with mental illness. The hospice founded in the sixth century by the monk Theodosius near Jerusalem is supposed to have had a ward for those suffering from madness, and institutions for the sick, including the mad, were established from the seventh century in the Islamic world, which had a particularly humane outlook on mental illness. The grounds of the hospital for the mentally ill, built in the fifteenth century by the Sultan Bajazet II, were adorned with gardens and fountains, and treatment of the patients included a special diet, baths, perfumes, and concerts. Mental institutions were established in various parts of Europe from the twelfth century onward, the most famous of these being St. Mary of Bethlehem—later known as Bethlem or “Bedlam” (from which we get the synonym for “pandemonium”). Bethlem was founded in 1247 in London, and by the late fourteenth century, was housing the mad. Eventually madhouses became businesses as well as charitable institutions, and by the middle of the nineteenth century, the “trade in lunacy” had absorbed about half of those with mental illness.
In the nineteenth century, the asylums of Europe were revolutionized by reformers who were driven by both humane and medical motives. Reform was desperately needed because asylums were not hospitals; they housed the mad but didn’t treat them, and the conditions in some asylums, especially those funded from the public purse, were horrific. Johann Reil, the nineteenth-century doctor from whom we get the term psychiatry, expressed outrage at the state of Germany’s asylums: “Like criminals we lock these unfortunate creatures into mad-cages, into antiquated prisons, or put them next to the nesting holes of owls in desolate attics over the town gates or in the damp cellars of the jails, where the sympathetic gaze of a friend of mankind might never behold them; and we leave them there, gripped by chains, corrupting in their own filth.” Elsewhere in Europe, conditions were as bad or worse. The Chantimoine tower in Caen, Normandy, for example, held a number of prisoners who were mad. In 1785 the tower was demolished, and the report of the demolition describes one of the inmates: “in the thickness of this tower’s corner we found and pulled out . . . Jean Heude, called Bame, a tall and strong man incarcerated for twenty years, raving mad, naked and dangerous, whose door had not been opened for so long that the lock had to be knocked off with an iron bar.” Symbolic of the inhumane state of Britain’s asylums was the case of William Norris, an American marine who had been committed to Bethlem in 1801. An extremely violent man, he proved too dangerous to handle like an ordinary inmate. Bethlem’s solution was to pin him to a wall with iron bars and put a chain around his neck that could be tightened from an adjacent room. When the Quaker reformer Edward Wakefield visited Bethlem in 1814, Norris had been shackled in this position for ten years.
In France, asylum reform was fueled in part by the revolutionary aspirations of liberty, equality, and fraternity. The political transformation of 1789 fed into a movement to storm, metaphorically, the Bastilles confining the mad. In 1793, as the story goes, in the spirit of the revolution, the asylum doctor Philippe Pinel liberated the inmates of the Salpêtrière Hospital from their chains, and with that act psychiatry was born. It was, in fact, Pinel’s lay colleague at the Bicêtre, Jean Baptiste Pussin, who struck off the chains of the inmates, with Pinel following suit at the Salpêtrière, but Pinel remains the hero of the Whig history of psychiatry.
Crusaders such as Wakefield had been galvanized by moral outrage, whereas medical reformers believed that humane conditions would lead to better clinical outcomes. In 1813, Samuel Tuke, the grandson of the reformer William Tuke, published Description of the Retreat, which gave an account of a new form of asylum established by his grandfather in 1796. In contrast to the prison-like Bethlem and its ilk, the purpose of Tuke’s asylum was to treat the mad rather than confine them. Advocates of the “therapeutic asylum”—Tuke and William Battie in England, Vincenzio Chiarugi in Italy, and Pinel in France—were Enlightenment men who were convinced of the power of reason and the possibility of cure by means of what Pinel called “moral (i.e., psychological) therapy” of patients, in which the doctor took “on an air of bonhomie and a tone of extreme frankness” in order to “penetrate into their most secret thoughts, clear up their anxieties, and deal with apparent contradictions by comparing their problems to those of others.” By 1813, the idea of the therapeutic asylum had been around for more than sixty years, but Tuke’s book marked a turning point.
Figure 4: A Rake’s Progress, Plate 8: In the Madhouse, William Hogarth, 1735. The painting shows two women “of note and quallitie”—the sort of people who were encouraged by the Governors of Bethlem to visit the hospital to view the “poore Lunatiques” for the edification of both visitor and inmate. Charles Deering McCormick Library of Special Collections, Northwestern University Library.
Figure 5: Portrait of William Norris at Bedlam, George Arnald, 1814, Clements C. Fry Collection, Yale University, Harvey Cushing/John Hay Whitney Medical Library. Reproduced with permission.
One antecedent of moral therapy was new thinking about madness as a psychological phenomenon. From the time of Greek antiquity, as we’ve seen, madness had been understood to be either a disturbance of the soul or the body. By the nineteenth century, however, the debate about madness concerned whether it was a bodily disease or a mental one. The forerunner of the mentalist camp was John Locke, the great seventeenth-century empiricist philosopher. Locke (whose views laid the foundation for modern psychology) conceived of the mind as a storehouse of “ideas,” and thinking as a matter of their recombination. The madman, Locke said, puts “wrong ideas together.”
Locke’s views entered psychiatry by way of the Scottish physician William Cullen, who worked at the University of Edinburgh, the preeminent medical school of the second half of the eighteenth century. A goal of psychiatry at that time was to produce a taxonomy of mental illnesses, and Cullen became the great classifier who did for psychiatry what Linnaeus had done for biology. Cullen believed that mental disorders were indeed diseases of the nervous system, and he coined the term neurosis to designate them. In a remarkably prescient way, he hypothesized that the “nerve fluid” by which the brain functioned might be electrical and that mental disorders might come about by nervous over- or under-excitation. But in the spirit of Locke, he claimed that the effect of these neuroses was a psychological one—a “hurried association of ideas” producing “false judgement”—and under the influence of Cullen’s views, the mind of the mental patient came to the fore in medical thinking about insanity and its treatment. Until the advent of psychoanalysis, however, psychiatric research was overwhelmingly concerned with the brain rather than the patient. If the new asylum were to offer psychological therapy, there would have to be doctors to man them, and this new generation of asylum doctors were the first professional psychiatrists. Their concern was their patients. Understanding the root causes of mental illness would have to wait.
Unfortunately, clean sheets and fresh air can only do so much to treat mental illness, and while some patients improved with informal psychological therapy, it did little for most of them. Without the hoped-for clinical success of moral treatment, the new high...
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