Madness: A Very Short Introduction - Andrew Scull 2011

Madness unbound

Qu’on ne dise pas que je n’ai rien dit de nouveau: la disposition de matèries est nouvelle....

[Lest anyone is inclined to say I’ve said nothing new here: the arrangement of the materials is new.]

Pascal, Pensée 22 (1662)

Madness is something that frightens and fascinates us all. It is a word with which we are universally familiar, and a condition that haunts the human imagination. Through the centuries, in poetry and in prose, in drama and in the visual arts, its depredations are on display for all to see. A whole industry has grown up, devoted to its management and suppression.

And yet madness is no longer an acceptable term to use in polite company. For psychiatrists, its use is a provocation, an implicit rejection of their claims to expertise in the diagnosis and treatment of mental disorders, and symptomatic of a wilful refusal to accept the findings of modern medical science. For many of those suffering from serious disturbances of emotion and cognition, and for their friends and relations, it is an insult, a stigmatizing and hurtful anachronism that should be dead and buried, like the Victorian bins that once shut up so many of the lunatic in what at the time was pronounced to be a therapeutic isolation.

So the title of this Very Short Introduction is bound to provoke, to raise hackles, in some quarters to infuriate. And perhaps that is a good thing. For our subject is precisely something that profoundly disturbs our commonsense assumptions; threatens the social order, both symbolically and practically; creates almost unbearable disruptions in the texture of daily living; and turns our experience and our expectations upside down. Besides, this is a work of history, and till the last two centuries, ’madness’ was a term widely and unselfconsciously employed by both sufferers and their would-be healers, as well as by society at large. If a once respectable word has now become linguistically taboo (except, ironically, among some of the mentally ill themselves, who defiantly embrace it as part of their rejection of the psychiatric enterprise), that very process is part of what I shall explore and comment upon here.

Madness is not a medical term (though it was once widely used by medical men). It is a commonsense category, reflecting our culture’s (every culture’s?) recognition that Unreason exists, that some of our number seem not to share our mental universe: they are ’irrational’; they are emotionally withdrawn, downcast, or raging; their disorderly minds exhibit extremes of incomprehensible and uncontrollable extravagance and incoherence, or the grotesquely denuded mental life of the demented. Pace the Thomas Szasz’s of this world, who proclaim mental illness a myth manufactured by a malevolent medical profession, it is vital to acknowledge at the outset the havoc, the disturbance, and the disarray that madness produces, and the pain and suffering it imposes on the sufferer, the intimate social circle he or she moves in, and the larger society. Madness may be a social fact, as the French sociologist Émile Durkheim might say. Its manifestations, its meanings, its consequences, are most certainly deeply affected by the social and cultural context within which it surfaces and is contained. But it is emphatically not something created by social labels, save in a purely tautological sense. Nor, in the final analysis, is it simply a social construct. Such romantic illusions will not inform the discussion that follows here.

Let us begin, then, with the recognition that madness - massive and lasting disturbances of behaviour, emotion, and intellect - resonates powerfully in our collective consciousness. Lunacy, insanity, psychosis, mental illness - whatever term we prefer, its referents are disturbances of reason, the passions, and human action that frighten, create chaos, and yet sometimes amuse; that mark a gulf between the commonsense reality most of us embrace, and the discordant version some humans appear to experience. Its existence has given birth to elaborate sets of social institutions and systems of knowledge that seek to comprehend, to contain, to manage, and to dispose of powerful symbolic and practical challenges madness poses to the social fabric and to the very possibility of social order.

As we shall see, social responses to madness, our interpretations of what madness is, and our notions of what is to be done about it, have varied remarkably over the centuries. On another level, the very seriousness of the challenges that madness represents have made lunacy a subject that has repeatedly attracted the attention of writers and artists, to say nothing of those who profess to possess a deeper understanding of its sources, its treatment, perhaps even its cure. It is those historically and culturally variable responses, and that deeper engagement with the existential meaning of madness, that will form the subject of this Very Short Introduction. My focus will be on the Western world, from the ancient Greeks to the present - a sort of ’Madness and Civilization’, if you like, but not one viewed through a one-eyed Foucauldian lens. Madness in the Muslim world, in India, China, and Japan, in the colonial and post-colonial worlds - those are topics I shall touch upon lightly, if at all. We shall have more than enough with which to occupy ourselves without straying into those territories.

One further preliminary point: like many a commonsense term, ’madness’ is somewhat imprecise. Just how bizarre or disruptive must someone’s emotions or thought processes be before the label is invoked? Self-evidently, that varies across time and place, across lines of gender, class, and so forth, albeit in non-random and sociologically explicable ways. There are forms of alienation so extreme - perhaps we can call them ’Bedlam madness’ for convenience, after the most famous madhouse in the English-speaking world - that they are unambiguous and obvious to all competent members of a given culture. But there are other varieties that hover on the borderlands, their status uncertain and contested. Are they part of a continuum of human psychopathology, or is there a sharp division observable here? Between madness and malingering, let us say, or between insanity and eccentricity, or between psychosis and neurosis? Historically, the verdict has varied. Here, I shall embrace and discuss such ambiguity, not deny or minimize it. And we shall have occasion towards the end of the discussion in this book to examine the peculiar edifice modern psychiatry has constructed to try to obfuscate and obscure the existence of continuing profound uncertainties about how to establish the boundaries between the mad and the sane.

For despite the fact that contemporary psychiatry seeks to promulgate a notion of madness as the external manifestation of a badly wired brain, the consequence of faulty biochemistry or an excess or deficiency of certain neurotransmitters, the process of drawing boundaries around the mad remains an uncertain and contested activity, the site of recurrent controversy that only occasionally has analogues in other branches of medicine. No X-rays, no PET scans, no laboratory tests exist that unambiguously pronounce that one is sane, this one mad. Despite the frantic and endlessly repeated efforts of the committees charged with writing and re-writing the Bible of psychiatric practice, the Diagnostic and Statistical Manual of the American Psychiatric Association, the boundary between sanity and madness remains permeable and contested, and the pretensions to have cut nature at the joints in differentiating hundreds of types and subtypes of mental disorder are exactly that, an elaborately disguised game of make-believe. Just as, on a very different plane, the moral and social status of the mad and their doctors continues to occupy a very uncertain terrain.

Is madness all in the mind, a group of psychological disturbances to be understood (and perhaps largely treated) through talk, or manipulating the social-psychological environment of the mental patient? Is it, on the contrary, a somatic disease like any other, the manifestation of a brain and body gone awry? If the former, then perhaps madness has meaning, and reveals something central about ourselves and our very identity as human beings. If the latter, then aren’t the mental symptoms that prompt some to seek help lest they ’lose their minds’, and others to intervene to impose some organized and more or less exclusionary response on those perceived as a threat, nothing more than noise? Then the search for meaning is a fool’s errand. Rather, we should commit ourselves to neuroscience and to unravelling the mysteries of the human brain.

The difficulty we confront in addressing such issues is twofold: on the one hand, of course, definitive answers to them remain remarkably elusive; and on the other, such antinomies may be badly framed, posing these issues as either/or questions, when reality may need us to see them as both/and formulations. There is no shortage of zealots who proclaim otherwise, and they are not a new phenomenon. Two centuries ago, one of Bedlam’s doctors, William Lawrence, proclaimed that deranged thoughts ’have the same relation to the brain as vomiting, indigestion, heartburn, to the stomach, cough, asthma to the lungs, or any other deranged functions to their corresponding organs’ (1816). By the late 19th century, with equal certainty, the professional consensus was that the mad and the mentally infirm were a biologically defective lot, their madness the product of deformed brains and inferior heredity. In the first half of the 20th century, that led the United States Supreme Court, citing these established findings of medical science, to license the involuntary sterilization of the mentally ill and mentally defective. As Justice Oliver Wendell Holmes memorably phrased the principle, in dealing with a case of alleged lack of mental development, ’three generations of idiots are enough’. Not much more than a decade after that court decision, Hitler’s Germany took such notions to their logical conclusion: with the active and enthusiastic participation of many German psychiatrists, mental patients were sent in their thousands to the gas ovens. (More than 70,000 were gassed in just 20 months, beginning in January 1940.)

By the end of the Second World War, however, the leading lights of American psychiatry were singing from a very different hymnbook, proclaiming that the ’refrigerator mother’ was at the root of all the cases of schizophrenia jamming the wards of state mental hospitals. The most dreaded of the psychoses thus had psychological roots and (so it seemed to them) was curable by talk therapy, a process Hollywood proceeded to retail to the masses in films like The Snake Pit and I Never Promised You a Rose Garden. In a dazzling reversal of received opinion, our own generation of experts has once more embraced biological reductionism, but modern psychiatrists can’t quite settle on what has gone haywire: genes, neurotransmitters, bad biochemistry of some other sort - and breathless proclamations that the conundrum has been solved simply fail to withstand scrutiny. With a few exceptions - the syphilis that once produced general paralysis of the insane; the dietary deficiency that gave rise to pellagra, and brought emotionally disturbed and demented patients into the asylum - the underlying mechanisms that drive people mad remain as elusive and unclear as ever. And the weapons we have to treat madness in its multitude of forms are still crude and rudimentary - at best capable of providing some symptomatic relief, not cure (the marketing copy of the pharmaceutical industry notwithstanding). A penicillin for disorders of the mind or brain remains a chimera.

If modern science and massive research programmes leave the aetiology of our schizophrenias and our bipolar disorders uncertain and mysterious, for our remote ancestors, the problem of how to account for (and cope with) the depredations of madness must have seemed even more daunting. Baffled by its presence, they often sought solace and explanation in the realm of the supernatural: the wrath of God (or the gods); possession by the Devil, or by evil spirits; bewitchment; the astrological influence of misaligned stars; sometimes even divine blessing or holy madness, for - perverse as it might seem - some forms of madness were interpreted in a favourable light. Even Socrates, in Plato’s Phaedrus, seems to endorse the paradox: ’Our greatest blessings’, he informs us, ’come to us by way of madness, provided the madness is given to us by divine gift.’

That was the nub of the matter, of course. For the spiritually enraptured, those who spoke in tongues, produced oracular utterances, and foretold the future, could equally well find themselves being viewed as out of their minds by those who did not accept that they were divinely inspired, as in 1 Corinthians 14:22—23. In related fashion, the notion that melancholy and genius might be closely allied had a pedigree that reached at least as far back as Aristotle (who numbered Hercules, Socrates, and Plato among the ranks of those so blessed and cursed). As a cultural trope, such notions would be given perhaps their fullest articulation in the work of the Renaissance scholar Robert Burton, The Anatomy of Melancholy.

Madness surfaces repeatedly in religious texts and practices. The Hebrew Bible is replete with stories of those bereft of their wits, raving, frenzied, or thrust into the depths of melancholy. In the Book of Daniel, Nebuchadnezzar, who had laid siege to Jerusalem and destroyed its temple, loses sight of who the real ruler is. In the midst of his boasts about his accomplishments, God teaches him the necessary lesson by reducing him to a bestial form of madness. As we learn from a clay tablet preserved in the British Museum, during seven long years, ’his life appeared of no value to him … he does not love son or daughter … family and clan does not exist’. Or, in the biblical version (Daniel 4:13), ’Let his heart be altered from that of a man, and let him be given the heart of a beast, and let seven seasons pass over him.’

1. The title page of the 1638 edition of Robert Burton’s The Anatomy of Melancholy, first published in 1621. A sprawling treatise, it ran to 900 quarto pages in its first published form

In Samuel (1 Sam. 15:1—3,8—9), Saul, the King of the Jews, rebels against God, failing to carry out to the letter divine instructions to slaughter the Amalek, ’both man and woman, infant and suckling, ox and sheep, camel and ass....and spare them not’. Though he ’utterly destroyed all the people with the edge of the sword’, he spared their king, Agag, and he spared ’the best of the sheep, and of the oxen, and of the fatlings, and the lambs, and all that was good, and would not utterly destroy them’. He was accordingly denounced by the prophet Samuel for his defiance of God. And shortly thereafter, so we are informed, ’the Spirit of the Lord departed from Saul, and an evil spirit from the Lord tormented him’. By turns fearful, raging, homicidal, and deeply melancholic, he languished for the rest of his rule in a state of intense mental turmoil, ending only with his self-inflicted death on the battlefield, where he faced certain defeat (presumably because of continuing divine displeasure) (1 Sam. 31). Prophets and mystics might alternately be regarded as intensely religious or as mad, as in Jeremiah (29:26). Indeed, as George Rosen has noted, the Hebrew for ’to behave like a prophet’ can also be rendered as ’to rave’ or ’to act like one beside himself’.

In the New Testament, there are still more vivid accounts of madness conceived of as possession, with Christ regularly pictured as casting out the demons (seven, so we are told, from Mary Magdelene alone (Mark 16:9; Luke 8:2—3)). On one notable occasion, Jesus is reported to have caused them to transmigrate into a herd of swine: ’and, behold, the whole herd of swine ran violently down a steep place into the sea, and perished in the waters’ (Matthew 8:32). With these divine precedents, prayer and exorcism were one remedy canvassed for cases of insanity among Christians, and suitable rites were accordingly made up by the Church to permit priests to cast out the Devil and his minions.

Madness is equally a staple of Homeric myth and of Greek drama. (Not for nothing would Freud dub the primal event in the formation of the human personality the Oedipus complex.) The machinations of the gods, but also the agonies of guilt and responsibility, the conflicts thrown up by duty and desire, the unshakeable effects of shame and grief, the demands of honour and the disastrous impact of hubris - in the dramas of Sophocles, of Euripides, and of Aeschylus, all too often these provoke the furies of madness: a rampaging Medea slaying her children; Heracles, foaming at the mouth, eyes rolling in their sockets, thinking he is killing Eurystheus’s children, but in reality dispatching his own; everywhere frenzy, anger, violence, and destruction stalk the stage. Here are images of immense power to shock, to provoke, to illuminate, even to provide emotional catharsis. They mark a literary and artistic fascination with madness that will persist throughout its long history.

Almost simultaneously, however, other Greek thinkers were developing a very different perspective on madness, one that emphasized its natural roots in disorders of the body. We used to speak in uncomplicated fashion of Hippocrates (c. 460—357 BCE) as the founding figure of the Western medical tradition, one whose writings were the source of a view of the origins of health and illness that would persist for more than two millennia. Nowadays, we more properly speak of the Hippocratic tradition, recognizing that the texts once attributed to one great man came from many hands, and a number of them were written down many years after Hippocrates’ death. But the model of sickness and its treatment outlined in these pages, modified to be sure by other Greek and Roman authorities, most especially Galen of Pergamum (131—201 CE), would become the ruling orthodoxy among the educated classes (and in bowdlerized forms among hoi polloi) until the very end of the 18th century and perhaps beyond, and the dominant ideology of those who proclaimed themselves doctors of medicine.

As modified by Galen, the Hippocratic system embodied what came to be a very broadly shared set of cultural understandings about the nature of disease and its therapeutics. At its core was the claim that the body was a system of inter-related elements that were in constant interaction with its environment. The system, moreover, was tightly linked together, so that local lesions could have generalized effects on the health of the whole. Each of us was composed of four basic elements which contended for superiority: blood (which made the body hot and wet); phlegm (which made the body cold and wet, and was composed of colourless secretions like sweat and tears); yellow bile or gastric juice (which made the body hot and dry); and black bile (which made the body cold and dry, and originated in the spleen, darkening the blood and stool). The varying proportions of these humours with which an individual was naturally endowed gave rise to different temperaments. But their balance was also susceptible to being thrown out of whack by a variety of influences: seasonal variation and developmental changes over the course of the life cycle, as well as a host of other potential sources of disturbance. Bodies assimilated and excreted, and thus were affected by such things as diet, exercise regimen, and sleeping patterns, and by emotional upsets and turmoil. There was, in other words, a clear recognition at the heart of this whole intellectual edifice that upset bodies could produce upset minds, and vice versa. The key to good health was keeping the humours in equilibrium, and when the patient fell ill, the physician’s task was to deduce what had become unbalanced and to use the therapies at his disposal to readjust the patient’s internal state. Body and environment; the local and the systemic; soma and psyche: each element of these dyads was capable of influencing the other, and of throwing the individual into a state of disease. Hippocratic medicine was, in every sense, a holistic system, one that paid close attention to every aspect of the individual patient, and tailored therapeutic regimes to each case. And, most importantly, it was a view of human health that emphasized the natural, rather than the supernatural, causes of disease.

As an intellectual construct, the humoral theory of disease was immensely powerful, making sense of symptoms, and pointing the way towards remedies for what had gone wrong. It simultaneously provided reassurance to the patient, and an elaborate rationale for the interventions of the physician. The Hippocratics did not emphasize human anatomy, save for their close attention to the external appearance of the body, and they actively avoided dissecting corpses, something that was almost taboo within Greek culture. Even the Roman physician Galen relied upon dissecting animals for his view of the way bodies were put together, so that mistaken views of human anatomy persisted in medical circles well into the Renaissance. But the Hippocratics’ rejection of the notion that either magic or divine displeasure played any role in the causation of disease was fierce and unambiguous, and their holism, and stress on the role of the psychosocial as well as the physical in bringing about ill health, encouraged them to proffer thoroughly naturalistic accounts of madness, alongside their explanations of other forms of sickness - indeed, to draw no sharp distinctions between the two.

There was much else to encourage a common approach to madness and more unambiguously physical disease. Distortions of perception, hallucinations, emotional upset and turmoil are frequent concomitants of being seriously ill. ’Fevers’, which we regard as symptoms but which for centuries were seen as the disease itself, could have a multitude of sources, particularly in an era when infectious and parasitic diseases were rife. And the delirium and altered consciousness, the raving and the agitation, that were fever’s frequent concomitants often resembled the disordered thinking of the mad. Many people had encountered (or deliberately sought) the cognitive and emotional disturbances that ingesting too much alcohol or partaking of other mind-altering substances brings in its train. And virtually everyone, then and now, had experienced moments of extreme psychological anguish, suffering, and pain. Emotional and cognitive dysfunctions were (as they remain) a familiar part of human existence, though for most of us, mercifully, a transient one. The analogies to madness were hard to miss, and the Hippocratics insisted that both had their origins in the underlying make-up of the human frame.

Where Aristotle had seen the heart as the seat of the emotions and of mental activity, Hippocratic texts saw the brain as their centre:

men ought to know that from nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations. And by this in an especial manner, we acquire wisdom and knowledge, and see and hear, and know what are foul and what are fair, what are bad and what are good, what are sweet and what unsavoury…

If it was the head, not the heart, which ruled, the encephalon was also where madness lurked:

It is the brain too which is the seat of madness and delirium, with the fears and frights which assail us often by night but sometimes even by day; it is there where lies the cause of insomnia and sleep walking, of thoughts that will not come, forgotten duties and eccentricities. All such things result from an unhealthy condition of the brain… when the brain is abnormal in moisture it is necessarily agitated.

And, as with other forms of ill health, the problem lay in an imbalance of the humours: too much blood led to warming of the brain, and hence to nightmares and terrors; too much phlegm might produce a mania whose victims

are quiet and neither shout nor make a disturbance…[while] those whose mania results from bile show frenzy and will not keep still, and are always up to some mischief.

The very term ’melancholy’ derives from the Greek word for black (melan) and the word for bile (chole). Hence depression as a black mood.

The Greeks and the Romans thus bequeathed both natural and supernatural accounts of the ravages of madness to subsequent generations. And rather than a single undifferentiated condition, those who wrote on the subject had distinguished a number of different varieties of the disorder. Whether these were distinct from one another or merely phases through which distraction might pass was the source of some debate, but a broad differentiation between mania and melancholia had been established and would persist through the centuries. There were still other variant forms of madness that existed on the borderlands of insanity. There was epilepsy, whose dramatic seizures were often preceded and followed by mental upset - a disorder whose victims included Julius Caesar. Here, too, there was no consensus on what was going on. Many called epilepsy ’the sacred disease’. As a Hippocratic text of this title scornfully noted:

Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like to other diseases…it appears to me [however] to be nowise more divine nor more sacred than other diseases, but has a natural cause [blocked phlegm] from which it originates like other affections.

Still another variant form of madness discussed by the learned was hysteria, characterized by fits, choking sensations, and mental aberrations - a disorder of women that some saw as a form of possession, and others viewed as still another illness brought on by the peculiarities of the female constitution, her moister, looser, more fragile body, and, most especially, her rampaging womb.

These distinctions and debates would begin to resurface centuries later in medieval and early modern Europe, but in the interim, in the West at least, the classical legacy was all but lost. For Greek and Roman writings - poetry, drama, histories, medicine - largely vanished from the scene in the aftermath of Rome’s decline and fall. Absent print as a means of preserving and readily disseminating knowledge, the transmission of classical culture depended upon the preservation and onerous reproduction of fragile manuscripts, and the continuity of an urban leisured culture that simply failed to persist. In the words of the great historian of late antiquity Peter Brown, in the West, ’classical culture went by default…[and but for developments elsewhere,] we should know nothing - except from fragments in papyrus - of Plato, Euclid, Sophocles and Thucydides’.

All, that is, might easily have been irretrievably lost had not some numbers of classical texts and a semblance of the old traditions survived in the East, first in the Byzantine Empire centred in Constantinople, and later, after the triumph of Islam, among Arab scholars and in the increasingly vigorous medical community that emerged in the lands under Islamic dominion. Here, to a large extent, was where Greek and Roman learning was preserved and argued about, translated into the vernacular, and then, centuries later, translated back from Arabic, Syriac, and Persian into Latin. By this circuitous route, from the late 11th century onwards, much of classical learning and, most importantly in the present context, ancient Greek medical ideas, attracted renewed interest in the West. Centuries later, they would constitute an increasingly important element in the debate over the origins and treatment of madness that would gain prominence in the Renaissance and early modern Europe.

Not that the problems posed by mental illness waited upon the revival of classical learning, or the interventions of a reviving humoral medicine. Medieval society still faced on a practical level the question of how to manage the mad, and continued to place primary responsibility for caring and coping with them, as best we can tell (for the surviving evidence is fragmentary and incomplete) on the family, and to a far lesser extent, the Church. The lunatic, that is, were left at large, their fate, like other largely dependent and helpless elements in society, at the mercy of whatever expedients their relatives could contrive, and of a haphazard and often ineffectual tradition of Christian charity and almsgiving.

Within the moral thought of the medieval Church, poverty, particularly if it were voluntarily assumed, was a position invested with considerable religious status and meaning, and charitable giving was urged on all good Christians. But neither the Church nor private individuals made any serious effort to match aid to need, though the great monastic foundations played a considerable role in the care of the unfortunate. A measured, calculated response to various forms of human misery was clearly foreign to a society where the impulse to give was governed largely by the desire to secure one’s own salvation. And besides, these were societies for which the margin between subsistence and starvation was narrow, and where famine, disease, violence, and early death were everywhere a looming threat. Madness was just one of a whole catalogue of misfortunes that threatened health and happiness.

Where families had the resources, the responsibility for the custody of the lunatic, guarding both their distracted relative and the community from harm, fell on their shoulders. Sometimes, the community might provide some temporary or permanent assistance to help them cope. If those expedients failed, then madmen might be left to their own devices. The deranged beggar, like the leper, was a familiar part of the medieval landscape, wandering from place to place, community to community, in search of alms. Shakespeare would make use of the enduring and iconic image of such Toms o’ Bedlam in King Lear, where the outcast Edgar disguises himself as mad, in other words,

’… the basest and most poorest shape

That ever penury in contempt of man

Brought near to beast. My face I’ll grime with filth,

Blanket my loins, elf all my hair in knots,

And with presented nakedness outface

The winds and persecutions of the sky.

The country brings me proof and precedent

Of Bedlam beggars, who, with roaring voices…

Enforce their charity.’

But charity could not be ’enforced’, of course, and while some have conjured up romanticized images of the fate of the mad left at large, and of the Middle Ages as an era when madness was seen as part of the continuum of human existence, there was little solace to be gained from the freedom to roam or rot. Not shut up, the life of the poor and mad, dependent and a burden, was almost certainly a Hobbesian existence: nasty, brutish, and short.

Matters might at certain times take an even nastier turn. Many forms of illness were seen as the result of moral failings or lapses, or the vengeance of a displeased God - a notion that persisted as a respectable belief as late as the 19th century, when divines proclaimed that epidemics of cholera were a sign of divine displeasure at the sinful state of society, and both the British Parliament and the American Congress called for national days of prayer and repentance to ward off God’s punishment. The Plague that carried out so large a fraction of the European population in the 14th century understandably was interpreted in this fashion, and madness likewise could readily be seen in supernatural terms - even by some of its victims, whose delusions often assumed such forms. Often, though by no means always, in a spirit-drenched world, where popular beliefs in devils and witchcraft were fervently held, the consequences could prove dire: the mad or those deemed to have cast spells on them to drive them to distraction might find themselves caught up in the mania for witch-hunting that periodically erupted in one community or another in a credulous Europe, and then they risked being cast into the flames. Thousands perished, and though by no means all witches were the mentally ill (or those blamed for fomenting mental illness), still ancient folk beliefs about madness and possession (which had, as we have seen, some biblical sanction) always created that danger.

Speaking of ’Bedlam beggars’ reminds us that the term was coined from the name of the most famous asylum in the English-speaking world: Bethlem (originally Bethlehem) Hospital, a monastic foundation dating from the 13th century that had begun to attract a handful of mad inmates from the late 14th century, and eventually came to specialize in the care of the insane. Hospitals were another institution that the Europeans had borrowed from the Arab world, and re-dressed in Christian garb. The Hotel Dieu in Paris, the Santa Maria Nuova in Florence, and St Bartholomew’s Hospital in London are all examples of such medieval foundations. In Spain, which had only gradually emerged from centuries of Islamic rule in the 12th and 13th centuries, there were as many as seven hospitals founded in the 15th century that, like Bethlem, came to specialize in the institutional confinement and care of the insane: in Valencia, Zaragoza, Seville, Valladolid, Palma de Mallorca, Toledo, and Barcelona.

Bethlem became so closely associated with the history of madness in centuries to come that allusions to it in a medieval context can easily mislead, especially when one acknowledges the emergence of a handful of comparable establishments elsewhere. In reality, it was an insubstantial, noisome place, poor, dirty, and tiny. In 1598, for instance, it contained only 20 inmates, a number that remained essentially stable for another half century and more. So its mere existence, and its later size and prominence, should not prompt any sense that institutional responses to madness were anything other than rare and exceptional even as late as the 17th century.

Early hospitals, of which Bethlem was one, were predominantly religious, not medical establishments (the word comes from the same root as ’hospitality’), and they served predominantly as way-stations for pilgrims and places of respite for the needy.

A number of them may have coped with the occasional mad inmate from time to time, and Bethlem’s gradual specialization in confining the insane was essentially a matter of pure chance, though serving as a lunatic asylum soon became its entrenched role. It was primarily a place of confinement in these years, one that, in Thomas More’s words, made use of ’betynge and correccyon’. An Indulgence issued in 1446 had already made clear that the ’miserable persons dwelling there…are so alienated in mind and possessed of unclean spirits that they must be restrained with chains and fetters’. Beyond such tantalizing glimpses, however, much about the treatment meted out at Bethlem in these years remains speculative and opaque. At best, our knowledge is fragmentary, though we can say with some confidence, echoing the hospital’s official historians, that ’there is very little evidence of formal arrangements to provide anything which, even on the most generous assessment, could be termed medical help’.

As the medieval world drew to a close, European societies continued, as they had for centuries, to grapple with madness in a variety of overlapping, often contradictory ways. That heterogeneity would persist long past the dawn of the modern age. But the 17th century would witness the beginning of a much greater fixation on the problems and meanings of madness, a heightened attention that quite early on manifested itself in the worlds of art, drama, and literature, and soon could be seen to surface in the world of practical affairs.