Madness: A Very Short Introduction - Andrew Scull 2011

Madness in chains

If we are to judge from its place in the literary and plastic arts, madness seems to have acquired a much greater cultural salience than hitherto in the period between the Jacobean age and the dawn of the 19th century. Playwrights of the late 16th and early 17th centuries made frequent allusions to Bethlem and its mad inhabitants. On the Restoration of the Stuart dynasty in 1660 following the idol-smashing puritan years of Cromwell’s Commonwealth, and in the immediate aftermath of the depredations of the Great Fire of London in 1666, Bethlem itself was rebuilt, moving from a dilapidated and boxed-in site in Clerkenwell to a prominent place in Moorfields, just north of the ancient heart of the city. Here, on a suitably liminal site, the filled-in ditch that ran alongside the old city wall, the Renaissance polymath Robert Hooke (who, together with Christopher Wren had designed the Monument to the Great Fire itself) created a spectacular new palace intended to display the benevolence and solicitude of London’s citizens, to symbolize the Restoration of royal and civic unity, and to connect the rule of the Stuarts to the restoration of the rule of reason. Bethlem Hospital launched a new moral architecture of madness, and over its gates were erected two emblematic statues, Raving and Melancholy Madness, by the Danish sculptor Caius Gabriel Cibber.

2. The new Bethlem Hospital in Moorfields, designed by Robert Hooke, and opened in 1676, a celebration of the Restoration of the Stuart monarchy in 1660, and with it, the rule of reason

A half century later, one of Hogarth’s best-known satirical prints would be set in its cells, a stylized precursor in its turn of Goya’s unforgettable rendering of the hellish interior of a madhouse.

As we move from the medieval to the modern world, in plays, in broadsides, and in ballads, in the pages of Don Quixote, and in the pioneering novels and pulp fiction of 18th-century England (from Smollett and Richardson to the authors of the first gothic tales), a fascination with madness is visible everywhere. In the written word; on the stage; in political pamphlets; in songs heard on the street; in architecture and sculpture; in painting and in the new mass-produced engravings: images of Unreason surface. Madness re-imagined emerges in a plethora of places, replete with portraits of barely contained violence and terminal despair, of chains, whips, and beatings, of confinement in barred cells run by ruffianly keepers, whole scenes that embrace the loss of reason among some who externally remain facsimiles of normal human beings, but who in fact have descended into, or even beneath, the ranks of the beasts.

Shakespeare makes madness a central theme in some of the greatest of his plays. Lear provides us with a Fool whose mental state licenses him to tell truths saner mortals dare not utter; another character, as we have already seen, who deliberately disguises himself as a madman and wanders naked through the countryside; and the king himself, pleading ’O, let me not be mad, not mad, sweet Heaven! Keep me in temper; I would not be mad!’ - and mad becoming, as Fate and his own foolishness bring successive hammer blows upon his head. Hamlet’s behaviour - bullying and betraying poor Ophelia, pretending to love her and scorning her, then killing her father - drives her out of her wits. She becomes a pitiable creature,

Divided from herself and her fair judgement

Without which we are pictures [i.e., mere facsimiles of a human being] or mere beasts.

The chaste maiden thus reappears on stage singing bawdy and mad songs and speaking in riddles, then disappears, wandering down by a river bank and clambering on to the branch of a willow, whence she

Fell in the weeping brook. Her clothes spread wide

And, mermaid-like, awhile they bore her up;...

Till that her garments, heavy with their drink,

Pull’d the poor wretch from her melodious lay

To muddy death.

If Ophelia becomes an iconic figure of a woman driven mad by mistreatment and loss (her drowning re-imagined by Millais two and a half centuries later in one of the most famous of the Pre-Raphaelite paintings), what then of Hamlet himself? His creator makes of him the very model of ambiguity and uncertainty, Hamlet’s irresolute waverings and inability to act mirror our uncertainty as his audience about his very sanity. Is he play-acting? After all, he tells his friends he may have occasion to ’put an antic disposition on’, and he insists, when others doubt his sanity, ’I am but mad north-north-west: when the wind is southerly I know a hawk from a handsaw’. But his introspective melancholy, his meditations on suicide, his inappropriate and blunted emotional responses - to Ophelia’s death and much else besides - suggest that his madness is more than merely feigned. For Shakespeare’s contemporaries, as other historians have noted, the issue may have been moot. A number of them have argued that audiences when the play was first presented may well have taken it for a straightforward revenge tragedy. But by the early 18th century, and most certainly ever since, the issue of the status of the prince’s ’madness’ has been recurrently a matter of debate. Not so Lady Macbeth, unhinged by the consequences of her vaulting ambition and its murderous enactment:

3. Ophelia, by Sir John Everett Millais (1829—96). This painting of Ophelia still afloat, singing her mad songs, aroused controversy and harsh criticism as an affront to popular taste when first exhibited in 1852. In the words of the reviewer for the Atheneum: ’There must be something strangely perverse in an imagination which souses Ophelia in a weedy ditch, and robs the drowning struggle of that lovelorn maiden of all pathos and beauty, while it studies every petal of the darnel and anemone floating on the eddy.’

Out, damned spot! Out I say...who would have thought the old man

to have had so much blood in him?...Here’s the smell of the blood

still. All the perfumes of Arabia will not sweeten this little hand.

Her mind is fatally infected, and ’More needs she the divine than the physician’.

Images of madness were a familiar sight elsewhere on the Elizabethan and Jacobean stage: in Marston’s What You Will (’Shut the windows, darken the room, fetch whips: the fellow is mad, he raves - talks idly - lunatic’) and in Shirley’s Bird in a Cage (in which the madhouse is referred to as ’a house of correction to whip us into our senses’), in Thomas Decker’s The Honest Whore, Fletcher’s The Pilgrim, and Middleton’s The Changeling. Indeed, it was the commonplace character of these associations that allowed writers not only to employ them to arouse terror, pity, and disgust, but also to make use of them for satiric and comic effect. Shakespeare, of course, was not slow to exploit these dramatic possibilities, as when the disguised Rosalind teases the love-sick Orlando in As You Like It:

Love is merely a madness; and I tell you, deserves as well a dark

house and a whip as madmen do; and the reason why they are not

so punished and cured is, that the lunacy is so ordinary that the

whippers are in love too.

Or, in a variation on the same theme, when Theseus in A Midsummer Night’s Dream, informs Hippolyta that:

Lovers and madmen have such seething brains,

Such shaping fantasies, that apprehend

More than cool reason ever comprehends.

But it was Don Quixote that provided their most sustained and hilarious instantiation, its first instalment appearing just as Lear received its first public performance. Mad Quixote clearly is, obsessed and hallucinating, incapable of perceiving the world as others see it. His craziness is perceived and mocked, even assaulted, by those around him. And tormented he equally is, physically in Part One of his adventures, and psychologically in its sequel. Here was a mock-heroic masterpiece featuring our would-be knight errant famously tilting at windmills and fighting with sheep, sheep that the mad Quixote transforms into two onrushing armies: ’He rushed madly this way and that. The sheep were routed and trampled upon in a most terrible manner.’ And then the shepherds, protecting their flocks, turn on him, pelting him with stones and tumbling the bleeding Quixote from his saddle. When Sancho Panza reproaches him for assaulting the poor beasts, Quixote insists they were indeed armies of soldiers, and that ’at the very moment that my victory was complete, my old enemy changed the routed army into a flock of sheep. It was all done to rob me of the glory that belonged to me.’

Cervantes’ world of folly would find its anglicized echo a century and a half later, in Tobias Smollett’s Sir Launcelot Greaves, a novel that ends with both hero and heroine trapped in a madhouse run by the eponymous Bernard Shackle. Madness was now a territory that writers in a variety of genres continued to exploit and explore. Growing affluence and literacy spawned much greater audiences for fiction, and sentimental novelists were not slow to take advantage of the commercial opportunities that now opened up. Henry MacKenzie, one of the prime exponents of this mawkish but lucrative market, promptly sent one of his most popular heroes on a visit to Bethlem, where the sight of the poor lunatics prompted one of those floods of tears that the author of The Man of Feeling repeatedly inflicted on his readers. And still further down-market, the gothic novel made its debut, one of its stock plot devices involving the confinement of the innocent hero (or preferably heroine) in the cells of a madhouse, presided over by unscrupulous ruffians.

From Eliza Haywood’s The Distress’d Orphan, or Love in a Madhouse (which first appeared in 1724 and stayed in print till the end of the century), through Mary Wollstonecraft’s Maria; or, the Wrongs of Women (which was published in 1798), madhouse scenes were almost de rigueur, posing titillating threats to both the chastity and the sanity of the women corruptly consigned to this sort of living tomb. Annillia, Haywood’s heroine, having refused to marry her cousin and give him her fortune, is carried off by her uncle’s minions ’in the dead of night’ to one of these establishments. Here this genteel and virginal creature finds herself among the Bedlam mad:

The rattling of Chains, the Shrieks of those severely treated by

their barbarous Keepers, mingled with Curses, Oaths, and the

most blasphemous Imprecations, did from one quarter of the

House shock her tormented Ears; while from another, Howlings

like that of Dogs, Shoutings, Roarings, Prayers, Preaching, Curses,

Singing, Crying, promiscuously join’d to make a Chaos of the most

horrible Confusion.

Minor poets like Thomas Fitzgerald drew a contrast between the ’stately Fabric’ of the new Bethlem and the disorder that reigned within:

Woe and Horror dwell for ever here...

And Peals of hideous Laughter shock the Ear.

And within the confines of a very different genre, Alexander Pope and Jonathan Swift found few figures as well suited as the lunatic to serve as the focus of their satires. While Pope warned of a world about to be overwhelmed by dunces, in a characteristically excremental outpouring, Swift urged the madhouse keeper to stick to his task of reining in the mad:

Tie them keeper in a tether,

Let them stare and stink together:

Both are apt to be unruly,

Lash them daily, lash them duly,

Though ’tis hopeless to reclaim them,

Scorpion rods perhaps may tame them.

Meanwhile, on Grub Street, the Ned Wards of the world, journalists on the make, retailed the standard literary clichés, as they entertained their audience by providing what purported to be naturalistic descriptions of the antics of the Bedlamites:

such a rattling of chains, drumming of doors, ranting, holloaing,

singing, and rattling, that I could think of nothing else but Don

Quevado’s vision where the damned broke loose and put Hell in an

uproar.

It was Bethlem, indeed, that dominated 18th-century portraits of lunacy, verbal and visual. Foreign and domestic travellers both made a point of visiting it. It had already acceded to a status it has never relinquished, the mythical and mystical Bedlam of our imaginings: the scene of riot, turmoil, and tumult - a veritable (or perhaps not so veritable - for many Bethlem legends have little foundation in fact) theatre of folly, where Reason wrestled with the demons of Unreason in a continuing drama of brutal beatings and callous cruelties. Most famously, Bethlem featured as the climax of William Hogarth’s didactic series of panels on the wages of sin, A Rake’s Progress. Young Tom Rakewell, having suddenly come into a fortune, spends wildly on drink, fine clothes, and prostitutes. A series of paintings vividly captures his dissipation and decline, till the eighth scene presents us with the consequences of his debauchery: half naked, head shaved, he lies in Bedlam, being manacled by a keeper and with a plaster covering the wound where he has been bled, his spurned sweetheart kneeling and weeping by his side, amidst a panoply of depraved and raving lunatics.

4. A Rake’s Progress by William Hogarth (1697—1764). The eighth and last panel in a didactic series that depicts Tom Rakewell’s passage from sudden wealth, via drink, dissipation, and debauchery, to madness and confinement in Bedlam. Originally painted in 1733, this engraved mass-market version was published two years later and was an enormous commercial success

What swiftly gave these paintings iconic status was Hogarth’s clever embrace of the improved techniques for engraving images that had emerged in the early 18th century, for these allowed him to mass produce black-and-white versions of the originals, and to present them to a middle-class audience eager to put on display a facsimile of aristocratic taste for art, and to advertise their own embrace of conventional morality. Hogarth had rendered the interior of Bethlem with remarkably fidelity (he would later become one of the hospital’s governors), and other artists soon followed his lead, making use of the dramatic possibilities of illustrating madness and the madhouse. Many pirated and simplified versions of the Rakewell image were rushed to market.

Later editions of The Distress’d Orphan carried engraved illustrations of Annillia being seized and carried off to the madhouse. ’Crazy Kate’, or ’Crazy Jane’, a servant girl seduced and abandoned by her cynical lover, had been sung about in ballads, and now appeared in a variety of portraits, always with staring, mad eyes, and often with other signs of evident distraction: straw in her hair, hands poised to scratch and assault, en deshabillé, with naked breasts provocatively on display. (A century on, the mad British artist Richard Dadd, confined successively in Bethlem and the new asylum for the criminally insane, Broadmoor, after he abruptly cut off his father’s head, would employ a male model - all that was available to him in his confinement - and paint a particularly striking variant of the genre, an indication of the continuing cultural resonance of these tropes.)

The leading satirical artists of the late 18th century, Thomas Rowlandson and James Gilray, returned again and again to the theme of madness, Rowlandson portraying the leader of the Whig opposition, Charles James Fox, maddened by ambition and trussed up in a straitjacket, being examined through a quizzing glass by the apparently equally mad John Monro, physician to Bethlem, before being carted off to the wing for incurable lunatics; and Gilray savaging both King George and the political classes more generally (not sparing the notorious Duchess of Devonshire) as mad creatures leading the country to rack and ruin.

And so to Francisco de Goya’s haunting images of the madhouse: not stylized satire, like Hogarth’s famous image, but searing, raw representations of the mad (perhaps a vision that captured his fears about the prospect of his own descent into madness). One such painting was of an interior, a chaotic scene, with half-clothed and naked figures, some in shadows, others bathed in light streaming through a high, barred window; another depicted an exterior, giving us a vision of naked madmen fighting amidst a collection of fellow lunatics indifferent to their fate, self-evidently too obsessed with their own wild imaginings to care about the violence being transacted in their midst. This was a nightmare world, akin to Goya’s terrible and shocking images of The Disasters of War, with all their unforgettable mixture of sadism, cruelty, and intimations of evil.

5. Crazy Jane, by Richard Dadd (1817—86). Confined as a criminal lunatic from 1844, first in Bethlem, and then, from 1864, in the newly opened hospital for the criminally insane, Broadmoor, Dadd remained a highly productive artist, painting this striking watercolour just a year before his death

If madness thus becomes a staple of works of the imagination in the 17th and 18th centuries, it also becomes a topic of new speculations by medical men, and others seeking to understand its mysteries. To be sure, much of the new medical literature on madness remained firmly within the ancient humoral tradition, whose flexibility and ability to integrate mind and matter, passions and bodily ailments, within a single over-arching system of explanation rendered it attractive to doctors and the educated laity alike. Its assumptions about the foundations of illness and health were deeply ingrained in European culture, and once within its magic circle, any disorder, any possible outcome could be provided with a name, a rational explanation, and a course of treatment, all of which were (as they remain in our own day) a source of great comfort and consolation, independent of whether they actually conduce to a cure. To be sure, a handful of dedicated anatomists, largely practising on the bodies of executed criminals, were finally revising the mistaken models of the human frame inherited from Galen. And one of these, Thomas Willis, the Sedleian Professor of Natural Philosophy at Oxford, had joined with others in giving prominence to a newer system of regulation of the body: the brain and the nervous system.

6. The Madhouse, by Francisco de Goya (1746—1828), painted c. 1812—14, and providing an unvarnished picture of the confinement of the insane

Hippocratic and Galenic medicine saw disease as constitutional, the upsetting of the body’s natural equilibrium. The ancients had looked to the balance or imbalance of the four humours - blood, black bile, yellow bile, and phlegm - to understand the systemic disturbances that produced the symptoms patients and their doctors observed. In turn, these understandings guided the physician in his choice of remedies, each aimed at getting the disease out of the body - via vomits, purges, bleedings, and measures designed to sweat noxious elements out; or by setting up sources of counter-irritation, blisters, setons, and the like, which could draw disease away from more critical areas of the human frame, and offer them a free passage out of the body in the form of pus.

The new doctrine of the nerves, put forth by men like Willis, the Swiss Albrecht von Haller, and the Scot William Cullen, was similarly systemic in its approach. Mind and body met and somehow interacted through the brain and the nervous system, whose ’animal spirits’ commanded and controlled the body. Hence, in Willis’s words, it was to ’the anatomy of the nerves’ that one should look, ’for by means of it, are revealed the true and genuine reasons for many of the actions and passions that take place in our body...’. Deranged nerves could be invoked to explain all manner of illness and pathology, nowhere more readily, of course, than in the case of the mad, and they could do so alongside more traditional accounts, which they supplemented rather than displaced. Taken up by new generations of doctors, Willis’s and Whytt’s notions of animal spirits moving speedily or slowly through the delicate network of tubes or fibres that made up the brain and nervous system soon acquired a widespread currency in lay as well as medical circles (for lay and professional conceptions of disease still overlapped very considerably, and the educated classes happily embraced these new-fangled, mechanistic ideas, which carried with them some of the prestige of the new Newtonian science).

Sufferers from milder forms of mental and emotional disturbance (’diseases’ many had been inclined to dismiss, then as now, as maladies imaginaires) hastened to employ the new language of ’nerves’, and as rapidly found society doctors all too willing to endorse such claims and to treat their disorders. Recalcitrant such disorders might be, but (partly in consequence) they were potentially enormously profitable. And behind them, of course, lurked more serious manifestations of a ’Machine out of Tune’, madness and lunacy: equally the product, as the English physician Nicholas Robinson insisted, of ’Changes in the Motion of the [nervous] Fibres’.

Others, too, were drawn to the intellectual puzzle that was madness. Philosophers like John Locke, delving into the mysteries of human understanding, were also tempted to discuss its absence or distortions. Lockean philosophy prioritized experience, and pictured the mind at birth as a tabula rasa, a blank slate, on which experience wrote its lessons. The education of the senses was thus the key to the development of human consciousness and to the production of regular patterns of thinking. Sensations were at once the mind’s servants, and the (not always secure) source of its provisional knowledge of the world: ’methinks, the understanding is not so much unlike a closet wholly shut up from light, with only some little opening left, to let in external visible resemblances’. In misconception lurked madness, for then one is led to draw:

a just inference from false principles...A madman fancies himself

a prince; but upon his mistake, he acts suitable to that character;

and while he drinks his gruel, and lies in straw, yet you shall see him

keep the part of a distressed monarch in all his words and actions.

Some modern commentators have been tempted to see in Locke’s views on the plasticity of human nature and the educability of man the source of a new, more optimistic view of madness, one that emphasized in a new way the possibility of cure, and even pointed the way towards a kinder, gentler treatment of the mad. That was certainly one possible inference from Locke’s views, and in the late 18th century a perspective that began to emerge in certain quarters. Equally, however, Locke’s views could license a fiercer response to the problem of how to break the preternatural hold mad ideas seemed to have over the minds of the lunatic.

The very tenacity with which maniacs adhered to their false and mistaken perceptions, heedless of the ordinary corrective processes provided by experience and persuasion, testified to the weight and strength with which they were impressed upon the brain. By implication, extreme measures might be required and justified to jolt the system back into sanity. Locke had emphasized the direct relationship between the strength of a particular sensation and the vividness of any given idea. Coupled with the notion that the cure of madness required the supersession of defective learned patterns of thoughts, such theorizing could provide the rationale for the employment of extreme forms of therapeutic terror. And this was no idle, abstract possibility. In England, in Germany, in France, in what would become modern Belgium, in the United States, the second half of the 18th and the early 19th centuries saw experiments with strange technologies to produce such severe frights: whirling chairs that affected both body and mind, producing ’fear, terror, anger and other passions’, but also rapid changes in the body, ’fatigue, exhaustion, pallor, horripilatio [hair standing on end], vertigo’, vomiting, and unconsciousness; ’baths of surprise’, where seemingly solid floors were designed to collapse and suddenly deposit unsuspecting lunatics in vats of cold water; elaborate contraptions that held patients under water and persuaded them they were about to drown; and the American Benjamin Rush’s famous ’Tranquillizer’, a chair that encased the madman’s head in a padded box that excluded light and sound, and kept his arms and legs pinioned in place, while warm and cold water was applied to head and feet.

Philosophical reflections on madness could thus have very practical applications. They also played an important and long-lasting role in medical theorizing about mental disturbance, an influence scarcely confined to that of British empiricists like John Locke. Indeed, the very model of a European rationalist philosopher, René Descartes, had arguably an even more pervasive influence on medical thinking, and, over the centuries since, the medical profession’s defence of its claims to jurisdiction over the management of the mad. The famous Cartesian aphorism, cogito ergo sum (I think, therefore I am), encapsulated a metaphysical dualism, mind and matter, body and soul, that had a long history in Western thought, but which here was advanced as the very foundation of all certain knowledge. The rational mind, identical to the immortal soul (and both ’l’âme’ in French), stood in contrast to the material, mortal body. By definition, the former was incapable of error (or could be drawn into error only by the failures of its means for perceiving the world and organizing humans’ response to it, the brain and the nervous system). Madness, thus, was rooted in the body, the natural province of the physician. To argue the contrary was to imply that the mind was subject to disease, debility, or even (in the case of outright idiotism) death; in other words, to contradict the very foundation of revealed religion and morality, the belief in an immortal soul.

7. ’The Tranquillizer’, the name given to this contraption by its inventor, the American mad-doctor (and signatory of the Declaration of Independence), Benjamin Rush (1746—1813). Designed to immobilize the patient, and shut out sound and light, it purported to act simultaneously on mind and body, and thus to calm those confined in it

Until well into the second half of the 19th century, medical men would rehearse these arguments, which rapidly became the ruling orthodoxy in their midst. While there were a handful of medical materialists, men who simply saw mind as epiphenomenal, that was a dangerous position, one that invited lay opprobrium and even professional ruin, as a few foolhardy souls discovered. By contrast, the adoption of Descartes’ dualism (whether or not one signed on to his fudge that the pineal gland was the location where the material and immaterial somehow blended), provided a wholly satisfactory account of madness’s origins, one that placed it firmly within the medical profession’s acknowledged sphere of expertise, and provided a powerful social warrant for its jurisdictional claims. ’From the admission of this principle’, as the Scottish psychiatrist W. A. F. Browne put it, ’derangement is no longer considered a disease of the understanding, but of the centre of the nervous system, upon the unimpaired condition of which the exercise of the understanding depends. The brain is at fault, and not the mind.’ ’In all cases where disorder of the mind is detectable’, he continued, ’from the faintest peculiarity to the widest deviation from health, it must and can only be traced directly or indirectly to the brain.’

These medical accounts of madness did not go unchallenged. On the contrary, older religious and even satanic explanations of mental troubles continued to have their advocates. Indeed, in England they were energetically put forward by evangelical Christians, most especially by the founders of Methodism, Wesley and Whitefield. Like other enthusiastic Protestants, they invested mental turmoil with profound spiritual significance. Anxiety and despair, the tortures provoked by the acknowledgement of guilt and sin, the perils of damnation and the promise of salvation, the literal struggle between the Divine and the temptations of the Evil One for the possession of an individual’s soul: these were central elements of new religious movements that steadily gained adherents in the 18th century. In such circles, scriptural discussions of demons and witches served to reinforce popular belief in an almost palpable spiritual world of supernatural malevolence, one of whose most visible manifestations were maladies of the mind. Religious revivalists thus helped to secure the survival of earlier perspectives on madness that mixed together religious and magical causation with naturalistic forms of explanation, and saw divine retribution, demoniacal possession, witchcraft, or the misalignment of one’s astrological signs as being as (or more) plausible an explanation of distraction as an account pitched in terms of bodily indisposition. Logically enough, Wesley and his followers developed alternative forms of religious and spiritual healing - vigils, fasting, and prayers - as a response to mental tribulations. To which the riposte of many doctors was that enthusiastic religion was itself a form of madness, or even, through its incitement of the fear of damnation, a potent cause of the disorder in those exposed to its doctrines.

The wildest, most threatening of madmen had always been liable to be locked up in some fashion - whether the improvised means of restraint adopted by desperate families, or the expedients used by the community: gaols, guard towers, and the like. In France, the royal authorities, fearful that the poor and the vagrant might be a threat to their power, sought, from the mid-17th century onwards, to confine the idle and the dissolute on a broader scale. Hôpitaux généraux, the first of which was established by royal decree in Paris in 1656, soon absorbed a sizeable fraction of these marginal populations, some of whom undoubtedly were mad. Beginning in 1764, when the hôpitaux généraux proved unable to contain all the beggars and whores, a parallel set of institutions, the dépôts de mendacité, were created, and these too took in numbers of lunatics whose families refused to care for them. In the principalities across the Rhine, later and in a much more haphazard fashion (which reflected the political fragmentation and heterogeneity of the German-speaking world), a variety of old buildings were recruited to confine a fraction of the dissolute and the idle. Again, some of the mad found themselves in these netherworlds, for lack of any alternative. But in neither case was there any attempt at a mass sequestration of the insane.

The late French philosopher-cum-historian Michel Foucault used the pages of his book Madness and Civilization to invent the notion of a Great Confinement of unreason during what he called ’the classical age’. He pictured the emergence of ’a social sensibility...that suddenly began to manifest itself in the second half of the seventeenth century...[one] that suddenly isolated the category destined to populate the places of confinement’. The upshot, he asserted, was a symbolic and literal caging of the mad, what he characterized as a revolutionary break with the past that saw the lunatics cast out from the community they had once moved freely amongst. Foucault’s was a seductive image, one that helped to make him famous and to attract legions of disciples. But for all that, it remains a late 20th-century ideological construct, one with little or no contemporary relevance or resonance in the societies it purports to describe.

There were, nevertheless, changes afoot in the handling of small numbers of the mad in this period, and they were changes that, in hindsight, would prove enormously consequential. At first, these emerged from a series of informal and pragmatic arrangements some families began to make with outsiders, to rid themselves of the social embarrassment, the never-ending emotional upset, the massive disruptions, and the physical threats that the presence of a mad relative in their midst inevitably brought in its train. Rather than attempting to care for the lunatic at home, arrangements might be made to board them elsewhere, where they might perhaps be less subject to neighbourhood gossip, and less able to create disruption and trouble. Entrepreneurs soon emerged willing to provide such services in a quasi-domestic setting, offering secrecy, as well as respite from near-overwhelming emotional and physical burdens. In France, these establishments became known as ’petites maisons’, and in England, as ’madhouses’.

In Georgian England, like much else in what was an extraordinarily innovative social order, the arrangements that emerged for handling the insane were ad hoc and unsystematic. Those entering the mad-business were drawn from a wide range of backgrounds - clergymen, both orthodox and non-conformist, businessmen, widows, surgeons, speculators, and physicians - any and all were free to enter the trade. In the absence of any official regulation or oversight, an open marketplace produced a predictably heterogeneous set of arrangements, with institutions varying widely in size, clientele, organization, and therapeutic regime. Here was a social space that allowed for considerable experimentation, and in the process contributed to the development of craft-based skills in the management of the mad. But here, too, was a school for scandal. The very nature of the mad-business, with its attendant secrecy and physical isolation, almost inevitably created gothic fantasies about what transpired behind asylum walls. And with an inverse relationship between the size of a madhouse keeper’s profits and the amount of money spent on his inmates, there were structural incentives for mistreatment.

What in England was dubbed ’the trade in lunacy’ almost immediately attained a cultural notoriety out of all proportion to the actual size of the industry. (Even by the end of the 18th century, no more than two or three thousand souls were confined in English madhouses, and probably no more than thirty to fifty practitioners were specializing in the treatment of the mentally disturbed.) The majority catered to the rich, for that was where the money was, but parishes were also beginning to get in on the act, paying small sums to those willing to provide places of confinement for difficult or impossible characters of a meaner sort - and in London, some of these establishments grew to a remarkable size, contained two, three, even four hundred at a time. But it is easy to overestimate the contemporary significance of these mansions of misery.

Although in theory madhouses might provide an invaluable mechanism for drawing a discreet veil over the mad relative’s very existence, rich families often recoiled from taking advantage of such sinister silences. At the other end of the social spectrum, public authorities were understandably reluctant to spend money incarcerating poor lunatics, save where the sheer extravagance of the mad person’s behaviour, and the perceived threat they posed to the surrounding community, prompted a more interventionist stance. (Likewise in France: the Hôtel-Dieu was by the surgeon Tenon’s account the only public provision in Paris in the late 18th century for such of the mad who might prove curable, and its two wards for the insane, tucked away in a huge ramshackle institution mostly devoted to the flotsam and jetsam of the capital, contained a grand total of 42 men and 34 women.) Demonstrably, most people preferred to seek other solutions to the problems their mad relations posed, and, if affluent, they possessed the means to do so. And yet the image of the madhouse acquired an ever greater hold over the public imagination.

In the protest pamphlets of a Daniel Defoe or an Alexander Cruden, the threats such places represented to the rights of the free-born Englishman (or woman) were prominently advertised. In the prose of the high-class novelist - Richardson, Smollett, MacKenzie - madhouse scenes and ruffianly characters served to titillate and entertain readers from the respectable classes. And for a larger mass market, the sinister and corrupt possibilities of these miniature worlds were employed to still more melodramatic effect, in tales of ’Pityless Monsters’ who ’delighted in inflicting Pain’; of females confined in ’Chains and Nakedness’; or of sane persons locked up and abused, till they were driven mad by the torments of their keepers, and the spectacle of their fellow inmates. So far as its public image was concerned, the madhouse was the Hades where increasing numbers of dead souls gathered to wallow in their miseries, and to be taunted and teased by those who proclaimed themselves their protectors.

As for those who presided over these establishments, many of the mad-doctors, as they came to be called, gained fortunes from meeting the demands and desires of their patients’ families. (Anthony Addington’s madhouse at Reading, for example, provided the foundation of the family fortune and his ascent to the rank of court physician, not to mention helping to underwrite his son’s rise to be prime minister of Britain.) But in return, they were the butt of satirical commentary, their social standing diminished by their participation in a speculative trade, their motives and competence routinely questioned and lampooned in pamphlets and the popular press. The commerce the mad doctor made out of madness left an indelible stain on his social pretensions. It was a lack of legitimacy that would cling to psychiatry ever after.