Madness has been blamed on everything from unbalanced humours to divine inspiration to possession by Satan. But what actually constitutes madness has shifted based on time and place. The author begins the book by defining madness as “a lasting and massive disturbance of intellect, reason and emotion”. This definition has often been used to describe mental illnesses that we now define as schizophrenia, psychosis, and bipolar disorder.
Our understanding of mental illness has changed wildly over time, indeed while “madness” has been viewed as a type of malledy for millenia, the idea of a special branch of medicine focused on the mind is really only about 150 years old. So why is it one culture may have seen madness as a health issue, while another saw it as divine punishment? Why did one view it as a sign of weak character while another viewed it as memories from past lives?
Chapter 1: Madness Has Been Thought To Originate In The Divine
One of the primary issues related to the understanding of madness over the centuries has been whether its cause is internal or external. The author begins with the bible’s story of King Saul, and is quoted as saying ““Saul is seen at one point as behaving like a prophet, then later on people see him as not entirely right in the head, attributing that to God punishing him for not slaughtering everybody when he was supposed to.”
In fact the author suggests that the claim that exorcism could cure madness was a big aid in Christianity’s spread in the first century AD, so much so that exorcisms were a standard practice for one to undergo prior to baptism. The Ancient Greeks and Romans on the other hand had a bit more sophisticated view, seeing madness as a disease that had its origins within biology.
Hippocrates, the Ancient Greek physician, was a proponent of humoralism; an early proto-scientific belief that the body was composed of four substances called humors. The four humors consisted of blood, yellow bile, black bile, and phlegm. Proponents of humoralism believed that ailments, both physical and mental, were caused by an imbalance in these humors.
And while the notion of humors may seem absurd to our modern eyes this was the first time in history that mental illness was treated as a medical condition with a materialist, rather than supernatural cause.
Chapter 2: The Golden Age of Islam and Medieval Europe
The passing of medical knowledge from one time period to another has been a winding zig-zag through different cultures. Much of what we know about Greco-Roman medicine for instance only survived due to the various Muslim empires.
By the time the Eastern Roman Empire, also known as the Byzantine Empire, fell in the mid 15th century it’s capital of Canstantinople was the largest repository of ancient Greek and Roman medical texts. Fortunately they survived the siege of the city thanks to Islamic scholars who translated, preserved, and learned from them.
The Islamic treatment of madness was an interesting synthesis of their own traditional belief that madness was supernatural and the result of a curse or malevolent spirits, with the Greco-Roman scientific view of madness as a medical condition.
Medieval Europe had a similar view to this, treating madness as both a supernatural and a physical ailment. Physicians made distinctions between madness they believed were caused by possession, which would be referred to a priest, and those they believed were physical in nature. Since European physicians at the time were also humoralists they saw the course of treatment for madness as being changes in diet, among other things, to balance the humors just as the Ancient Greeks did.
Chapter 3: The Scientific Revolution
The Age of Reason, also known as the scientific revolution, began in Europe in the 16th century and was a period of challenge to the authority and theology of the Catholich Church. The scientific method was first being developed and rational philosophy was challenging many notions regarding the supernatural.
For instance in the 1760’s Pope Pius VI ordered priests to stop performing exorcisms, which often targeted the disabled, due to criticisms by protestants that these were nothing but outdated superstitious practices. This denotes a significant change in the public perceptcion of the supernatural.
However accusations of madness were often used for political purposes to eliminate opponents or challenge the legitimacy of different denominations.
The author refers to the story of John Wesley, a methodist minister in England in the late 18th century, was a “forceful advocate of spiritual health of the mentally disturbed through communal rituals of fasting and prayer.”
Chapter 4: Society’s Disregard
For much of history the primary purpose of madhouses were not so much to treat the mentally ill, as to hide them. Those who suffered from mental illness or from mental disabilities were seen as an embarrassment for wealthy families who often paid immense sums for madhouses to take their ill and disabled family members, with no regard to whether or not those family members would actually receive care, just so they wouldn’t have to be seen or dealt with anymore.
These institutions often used their “patients” as slave labor or as the subjects of cruel human experimentation. The Bethlem Royal Hospital in England became so synonymous with mental illness that it became known as “Bedlam Hospital”. In fact in the 18th century it even became a tourist attraction, with visitors paying entrance fees to view the patients like animals in a zoo.
These tours were often used as a means of “moral instruction”, in which the ailments of the insane were depicted as being the result of immoral behaviors.
The practice of offloading mentally ill and disabled family members to abusive institutions continued well into the 20th century, with controversies such as the Willowbrook State School in New York City, a virtual warehouse for mentally disabled children who were left to live in squalor and filth, and regularly abused by the staff. The Kennedy Family famously had one of JFK’s sisters lobotomized rather than deal with her condition.
Even today prisons are the largest repositories of the mentally ill, used to keep mentally ill homeless people off the street. Out of sight out of mind.
Chapter 5: The Shift Towards The Asylum in The 18th and 19th centuries
Modern medicine and the actual scientific understanding of the body only really began in the 1700s and 1800s. Many illnesses were becoming defined and understood for the first time, cancers were being recognized, early forms of vaccination were being developed, and germ theory was beginning to be understood.
Even mental illness was being reconsidered as being caused by physical issues. Not by medieval concepts like humors, but an actual (albeit rudimentary) understanding of human anatomy.
However while reformists were arguing that the mentally ill should be treated humanely, the common assumption was still that the proper treatment was to educate patients on how to be more moral.
The asylum, which is to say a dedicated medical facility for the insane, first began to become common during this time period. The degree of humanity in these institutions varied wildly however. While some hospitals, such as the York Retreat, had relatively humane treatment and even early forms of what might be recognizable as talk therapy, others were little more than prisons used as punishments.
Anyone displaying abnormal behavior, from atheism to homosexuality, could be confined to these institutions indefinitely. No release dates or government oversight were needed. As stated in the last chapter many of these facilities weren’t abolished until the 1900s.
Chapter 6: A Different Perspective on the Causes of Madness
The term “madness” wasn’t just a colloquial word to denote insanity, it was a medical diagnosis. However the diagnosis was extremely broad, any mental abnormality was covered under the definition of madness. Madness was one singular condition.
It was only in the 1800’s that doctors began considering whether or not these different forms of madness were in fact different disorders altogether, and also began hypothesizing that circumstances and experience could contribute to one’s mental instability.
The hypotheses were varied, some doctors believed insanity was caused by an issue with the nerves or increased pressure or inflammation to the brain. Others suggested that stress could be a cause, such as experiencing war or political upheaval. It was at this time that termslike “nervousness” were starting to be used to describe certain conditions, in place of the catch-all “madness”.
The increasingly common practice of dissection and autopsy were also leading to new understandings of madness. Doctors studying the brain first discovered in the early 1900s for instance that syphilis lead to brain damage which in turn caused behavioral and mental problems.
It was also at this point that a new field of scientific inquiry specifically into the inner workings of the mind was starting to appear
Chapter 7: Freud, Psychiatry, and War
The beginnings of psychology as a field of science and medicine were characterized by the immense influence of one person; Sigmund Freud. An Austrian born in 1856, Freud founded the field of psychoanalysis. And while psychoanalysis, along with most of Freud’s theories, have since fallen out of favor, his contributions remain immeasurable.
Freud addressed mental illness from the perspective that the mind was a fluid and dynamic thing and as such its health could be affected by one’s experiences. He suggested that many, if not most, mental illnesses might be the result of trauma, and that our early experiences in life could affect how we function well into adulthood.
Freud also began the first ever systematic studies of childhood development, and was the first to introduce concepts like psycho-sexual development. Many of his conclusions seem confusing or even outright bizarre to us now, but at the time they were revolutionary.
Perhaps his most important impact however was the invention of talk therapy. The idea that an educated professional could help someone dealing with anxiety or depression by discussing their experiences and offering insight. These early methods of therapy were often clumsy or misguided, and relied on unscientific concepts like repressed memories, but the notion that past trauma could cause future mental issues proved to be prescient as one of the largest scale sources of trauma in history was about to occur.
Soldiers have been described as being haunted by their experiences in war for thousands of years. There was nothing new about the observation that going through was could affect one emotionally. However what we now call Post-Traumatic Stress Disorder (PTSD) goes beyond this, and observations of it really only began to first appear after the Civil War, and exploded after World War 1.
This wasn’t typical trauma. Soldiers were experiencing radically different symptoms, hiding under tables when they heard loud noises, going mute for years at a time, experiencing temporary blindness, exhibiting the famous “thousand yard stare”.
At the time it was called “shell shock”, and was often seen as a sign of weakness or cowardice. Treatments were often brutal and cruel, or often patients were just completely disregarded.
But it was early psychologists who began looking at this as something more systematic and sought to understand it.
Chapter 8: The Twentieth Century and Beyond
Modern psychology and psychiatry take a two pronged approach to understanding and treating mental illness. We now understand the brain is an organ like any other, its issues must therefore be similarly materialist in nature. The field of psychopharmacology has developed dozens of medications to help with a variety of mental illnesses from anxiety and depression, to Obsessive Compulsive Disorder, to Bipolar Disorder, to Psychosis.
Similar psychology has moved much closer to the realm of medical science than in Freud’s time. Scientific research has helped demonstrate what types of talk therapy are effective, and provide potential ideas as to why. Many forms of therapy, such as Cognitive Behavioral Therapy, are based on an understanding of the neurology of the brain.
However these fields are still in their infancy, and while we are able to figure out what works, we often don’t know why a treatment or medication works.
Similarly while the old mental institutions have been shut down, we still struggle with proper care for the mentally ill an disabled. As stated previously prisons are often a substitute for the untreated mentally ill. And even countries with universal health care often don’t have adequate mental health care coverage.
And despite nearly a century and a half of scientific study, the general public still often views mental illness as being illegitimate or a sign of poor character.
Chapter 9: Final Summary
In a way the history of humanity is the history of madness. How we have viewed madness is a reflection of the zeitgeist and culture of the times. In the past madness was viewed through the lense of religion and superstition. At other times madness was seen as a product of moral failures.
Our understanding of madness has mirrored out understanding, or lack thereof, of human biology. Even what we consider madness changes depending on the moral and societal standards of the times.How we treat the “mad” is a reflection of how caring, or uncaring, our society is. How we treat the least among us, the most vulnerable, is truly the litmus test for a just and fair society.