Madness

1.

During the last fifteen years, a series of semi-independent intellectual trends have come together to transform the history of what society has thought about madness and how it has treated those it considers mad. Once upon a time, the history of medicine was regarded, like that of pure science, as largely “internalist,” a story of how a progressive endeavor by a handful of gifted intellectuals slowly replaced superstition and error by empirical proven truth. More recently, however, historians of both science and medicine have begun to fit the protagonists in these ancient intellectual battles more deeply into their social settings. In the process, they have revealed a welter of unproven pseudo-scientific theories, professional or national rivalries, institutional jealousies, personal and professional ambitions, cultural conditioning, sexist and racist prejudices, political exigencies, economic incentives to save money, and religious biases, out of which new and powerful scientific and medical paradigms have emerged.

Some now argue that medical progress has been a power grab by the medical profession, and institutional treatment for the purpose of better care has been relabeled the “great confinement.” It is now credibly believed that hospitals were lethal death traps before Pasteur demonstrated the importance of a sterile environment. It is now also generally recognized that doctors may—presumably unwittingly—have killed more patients than they cured, certainly before the early nineteenth century, and maybe before the invention of anti-biotics in the mid-twentieth, and that their most valuable contribution to public welfare was psychological reassurance that help was on its way.

The most ambitious attempt ever made to examine the demography of early modern England concludes that the prolonged growth of population which began in the 1740s and only petered out during the last few years owed little, at any rate in its early stages, to a decline in the mortality rate. Medicine, therefore, can have had no part in the beginnings of the great demographic transition.¹

The beneficial effects of the medical profession are now thrown into doubt, and scientists generally are no longer regarded simply as wise men battling the mysterious forces of nature with supremely elegant conceptual thinking, and incredibly patient and exacting testing and retesting of data. Newton is now known to have been as concerned to establish the measurements of the temple of Solomon or to unravel the meaning of the Book of Revelations as he was to elucidate the laws of gravity or optics. James Watson’s frank disclosures in The Double Helix of the strength of personal ambition as a compelling motive behind scientific research has forever destroyed the image of the detached scholar selflessly dedicated to the pursuit of truth. The self-evident fact that exploitation by politicians of the recent discoveries of nuclear physicists is quite likely to result some time in the next few decades in the destruction of civilization, and possibly of most life on earth, merely reinforces this atmosphere of cynicism and suspicion.

The second trend has been a turning away from the history of elites, whether intellectual or political, to the history of the poor and downtrodden, a trend in which the nature of surviving documentation has inevitably also led to a focusing on social “deviants,” such as homosexuals, criminals, and the insane. One effect of this more catholic approach has been, in the case of the history of medicine, no longer to limit it to the study of orthodox medicine (as practiced, in England, by the members of the Society of Apothecaries and the Colleges of Physicians and of Surgeons) but to include also popular medicine, which antedates Galen and continues to this day to be far more widely used than orthodoxy likes to admit. Some of its practitioners were wise women, white witches, whose full significance has only emerged as a byproduct of yet another contemporary trend, a sudden revival of interest in the irrational in general and witchcraft in particular. Today the distinction between magic and science is no longer as clear-cut as it used to be, now that seventeenth-century science is seen as emerging from a strange brew compounded of Hermeticism, alchemy, and astrology.

Finally, interest in problems associated with madness and its treatment have been stimulated by the writings of Michel Foucault.² According to him, the whole post-Enlightenment attempt to treat the mad more humanely, and to devise positive ways to cure them, was largely an aspect of a drive to confine and isolate all deviants in society, to lock them up and throw away the key. It was part of what he calls “the great confinement,” other parts being the extensive growth of workhouses, schools, and prisons. In the eighteenth century, he says, the mad replaced the medieval lepers in isolation hospitals on the out-skirts of cities. There is, he claims, an identical attitude of mind behind the treatment of the two, and the places of isolation were the same.

Foucault is certainly correct that Enlightenment hopes of devising ways to reform criminals or cure madmen through incarceration have proved a gigantic failure. Today no one really knows what to do with either, except to lock up the former and drug the latter. Yet the residual belief remains that a test of the moral worth of a society is the way it treats its more impotent members, the indigent, the sick, and the mad. The battle has thus been joined between post-Enlightenment optimism about the power of society to provide remedies for human pain and suffering, and a cynical suspicion that any change is liable to be for the worse. The former effort reached its apogee in the mid-twentieth-century welfare state, and in America with President Johnson’s “Great Society.” Today, in 1982, there has re-emerged the older, more pessimistic view that nothing much can or should be done, and that whatever is done is morally corrupting to the recipients and financially crippling to the donors. So far as the mad are concerned, we are just about where we were five hundred years ago, when, in about 1450, a lord mayor of London concluded that “some be restored unto their wit and health again. And some be abiding therein for ever. for they be fallen so much out of themselves that it is incurable unto man.”³

What is not by any means so certain, however, is whether there is any firm basis in reality to Foucault’s vision of the “age of confinement.” Was there a major disjunction in Western treatment of deviants in about 1650, based on a new principle that madness is shameful, and that the best treatment is forcible isolation from society under management by professionally trained doctors? If this is so, was it merely the result of a conspiracy of professionals to seize power for themselves to lock people up and determine their treatment? That there was a trend toward confinement is undeniable, but the motivation is questionable. The mad were put into institutions at least partly in order to save them from exposure to greater cruelties at the hands of the public or their families. In any case, the few dangerously mad had been locked up in cages like animals from at least the late Middle Ages. So far from being isolated were the twenty-odd manacled madmen gibbering and rattling their chains in their filthy cages in Bedlam, one of the great tourist attractions of London from the early sixteenth century to the early nineteenth. It was one of the standard sights of the city, on a par with the royal tombs at Westminster Abbey, the lions prowling in the moat in the Tower of London, the flogging of half-naked whores at Bridewell, and the bull- and bear-baiting over the river at South-wark.

It has also been pointed out that there were enormous differences in the degree and organization of incarceration from country to country, England leading the way in private madhouses in the eighteenth century, and France in huge state-supported institutions. Moreover, the chronology is complicated, since the poor were the first to be incarcerated in large numbers in the seventeenth and eighteenth centuries, but the mad only in the nineteenth. In England in 1810, the total number of mad persons in confinement was only 2,500 out of a population of 9 million, or about 30 per 100,000, and the numbers did not begin to rise rapidly until the 1830s.

Foucault’s comparison of treatment of the mad during the early modern period and that of lepers during the Middle Ages does not stand up to close examination. Early modern madhouses were not disused leprosaria but evolved out of medieval hospitals, based on Arab models. Bethlem Hospital, or Bedlam, is one example. Lepers were condemned to lifelong isolation from the community, whereas very large numbers of the mad have always quickly come and gone. During the year 1788, for example, Bedlam held 282 different inmates, but it admitted 219 and discharged 205.⁴ This transit camp of the mind, with its constant turnover, was entirely unlike the lifelong prison of the medieval leprosarium.

Finally, Foucault’s attempt to link the treatment of schoolchildren, the poor, criminals, and the insane under a single conceptual umbrella, since all were subject to confinement, is both unhistorical and misleading. No serious scholar would doubt that the poor, in or out of workhouses, have been substantially relieved of the crushing burden of indigence in the last two hundred years, or that children, at least up to the 1960s, were increasingly better educated, and thus better prepared to take their place in society and better able to improve their chances in life. Moreover, poor parents willingly paid money to send their children to school, since they knew it gave them moral precepts, behavior discipline, and learning skills that would come in very useful in later life. Whether criminals and the insane have either benefited or suffered much from incarceration is an open question.

The central challenge of the Foucault model is to the humanitarian values and achievements of the eighteenth-century Enlightenment. The acute sensitivity to cruelty, and the vaulting ambition to cure social ills by the use of planning and science, were first made possible by the decline of religious faith in the late seventeenth and eighteenth centuries, which opened the way to a more secular view of human ills and their possible amelioration. Sins against the Holy Ghost and violations of God’s law such as heresy now took a lower priority than acts that were harmful to sentient creatures. It has to be admitted, however, that this desacralizing of traditional morality also opened the way to the use of cruelty as a value-free means to secular ends—political for Machiavelli, sexual for Sade, racial for Hitler. ⁵

Despite these possibilities, the Enlightenment was a force that in Western Europe resulted in the substitution of imprisonment for torture, mutilation, or death as the main punishment of poor criminals; the abolition of the slave trade; the reform of conditions in the prisons, which reduced opportunities for hideous cruelty (as well as those for easygoing tolerance of irregularities); the reduction and final abolition of the appalling floggings (up to 1,000 lashes) which were common in the armed forces; and the introduction of moral therapeutic methods of treatment of the insane.

The hostility to cruelty in the late eighteenth century covered so wide a front, ranging from the treatment of soldiers to that of criminals, chimneysweep boys, boxers, women mine workers, and baited bears, that denial of its reality flies in the face of the evidence. It also undercuts the basis of the whole liberal enterprise of the last two hundred years, which has done so much to diminish man’s personal and legal inhumanity to man. One has only to read how the medical profession treated King George III when he went mad—encasing his body in machinery, chaining him to a stake, beating him, starving him, threatening him, blistering and bleeding him, giving him digitalis, tartar emetic, and other noxious medicines—to recognize that the shift to “moral” treatment of the insane was a major amelioration of the human lot, regardless of its practical efficacy in making long-term cures, which admittedly was not great. It is not enough to advance the valid argument that more humane treatment of the insane depended on the revolutionary notion that the loss of reason was neither irreparable nor a cause to treat a human being like an animal, and that the cure depended on treating the mind rather than the body. It is perfectly true that theory determines treatment, but the wide extent of the humanitarian trend is still undeniable.

Foucault and his followers argue that it was the doctors who were behind the great confinement of the insane, where as in fact a better case can be made that they were merely responding to social demand. Society was willing and anxious to pay for incarceration. The private madhouses that sprang up all over England in the eighteenth century were run by entrepreneurs who supplied an expensive need of society. Large numbers of well-to-do families were now willing to pay to have their mentally defective children, or hysterical or merely redundant wives, or senile parents taken care of by someone else, out of sight and out of mind. There was push more than pull at work in the creation of the English private madhouses of the early eighteenth century, and even more in the building of the huge public asylums of the early nineteenth century. Moreover, all the children in school, as well as the insane in mad-houses, were paid for by their relatives or by the parish under the conviction, often fulfilled, that the experience would do them good. As for the helpless poor, some of whom were confined in workhouses, it is hard for anyone who has read about their conditions in eighteenth-century London or in France to believe that their lot has not improved since the age of confinement. This leaves only the poor criminals, and even they, if asked, would probably choose prison rather than the alternative penalties of severe flogging, mutilation, or execution.

Foucault thus provides us with a dark vision of modern society which accords with only some of the historical facts.⁶ Abstract and metaphoric in expression, unconcerned with historical detail of time and place or with rigorous documentation, Professor Foucault’s work has had an enormous and disturbing influence upon traditional views of recent Western history. By challenging the conventional wisdom of the Whig interpretation, he has forced the historians to turn to a careful investigation of the facts. He deserves full credit for drawing attention to the growth of confinement of a variety of deviants over the past two hundred years, for casting doubt on the motives of professionals, and for focusing attention upon the history of the treatment of insanity. It is he who has set the agenda for the last fifteen years of research.

2.

There are several possible ways of tackling the history of madness. One is by institutional histories of the places of confinement, the private madhouses and their successors the public asylums. Another is by a study of ideas about madness, particular types of madness, and how to treat them, in order to display changes in the underlying conceptualization of the mind/body problem, and changing roles of revealed religion, magic, and scientific medicine. A third is by seeking out the rare records of the host of unqualified practitioners, to see how they regarded patients, how their patients regarded them, who those patients were, and what treatments they were prescribed.

One type of madness, so-called “possession” in the sixteenth and early seventeenth centuries, has been made the subject of a brilliant little book by D.P. Walker, the implications of which are very far-reaching. Possession was a species of madness which could only be dealt with by magical means, since it was thought to be the involuntary occupation of an individual by a devil. The marks of possession were speech in an unknown language, knowledge of hidden secrets, supernatural strength, and horror at the use of sacred objects or words. Many of the possessed denounced their neighbors as witches, which led to the death of many innocent people. If fraud was not involved, the only possible explanation for such symptoms were possession by the devil, or some physical disease, such as epilepsy or hysteria. The Catholics chose the devil theory, and threw him out by the use of exorcism, a magical process using the Eucharist and other sacred objects and words to put the devil to flight; and the treatment often worked. Protestants, who believed that miracles had ceased with the apostles, had no such remedies to offer to the possessed.

Medical practitioners hastened to fill the void, for example in 1589 when the Throckmorton children were diagnosed by Dr. Barrow of Cambridge University as bewitched, on the basis merely of a urine specimen. The children caused the executions of three members of a family as witches, before “these abominable little girls,” as Dr. Walker rightly calls them, decided that the game had gone on long enough. Belief in possession was closely linked to belief in witch-craft. In 1600 a number of English writers were casting serious doubts upon possession as anything more than a mixture of melancholy and ambition for notoriety by young girls, working upon a popular belief in the stereotype of the witch as “an old weather-beaten crone, having her chin and her knees meeting for age…going mumbling about streets, one that hath forgotten her pater noster and hath yet a shrewd tongue in her head.”

But denial of the reality of possession led to denial of the reality of the devil, and denial of the reality of the devil was an encouragement to atheism, for “if no devils no God.” Dr. Walker suggests that women were particularly liable to possession since it was the only way they could draw attention to themselves, and get the chance to preach to a large audience. But in the long run the rejection of miracles by Protestants led to skepticism about possession; skepticism about possession led to skepticism about devils; skepticism about devils led to skepticism about witches; skepticism about witches led to a more rational religion; and a more rational religion opened the way to the development of early modern science. As John Aubrey remarked at the time, “Printing and gunpowder have frightened away the fairies.”

This is therefore a little book with brilliant insights and far-reaching conclusions, which do not differ in any major way from those of Keith Thomas in his Religion and the Decline of Magic. Dr. Walker has provided a superb case study of the transformation of the way early modern man looked at the world around him and how the medical profession established its hegemony over the treatment of madness. The only criticism one can make is that he is unreasonably rationalistic in his charges that most of the possessed were guilty of fraud rather than suffering from genuine psychosomatic disturbances.

3.

Another way to approach the history of madness is to investigate the vast underworld of unlicensed practitioners—wise men or women, magicians, astrologers, amateur clergy, and downright quacks. Taken all together, it is clear that in the towns the total number of these practitioners per capita was very large indeed, even by modern standards, perhaps as high as one per 250 to 400 inhabitants. The quantity was therefore ample, whatever may be said about the quality of the treatments prescribed. In sixteenth- and seventeenth-century England, even country people had someone to turn to—more often than not an unlicensed practitioner—within five miles.⁷ The problem for the historian, however, is to find out about these practitioners and their patients, since the former did not normally keep records, and if they did they tended to be destroyed.

Every now and then, however, an inquiring scholar stumbles across some unknown and revealing cache of documents, and if he has the imagination to see the possibilities (and the stamina to carry out the enterprise) he stakes out his claim and starts digging. About ten years ago, Professor Michael Mac-Donald found one such gold mine—a series of detailed casebooks of 60,000 consultations over a period of thirty-seven years from 1597 to 1634, kept by the most popular practitioner of both physical and psychiatric healing we know of in early seventeenth-century England. What makes this study so important is not only the scale and detail of the documentation but also the intellectually ambiguous position of the practitioner himself, the Reverend Richard Napier.

Napier was teetering unsteadily on the edges between magic, astrology, alchemy, religion, and the contemporary medical pharmacopeia, and was uncertain in his own mind where truth and efficacy lay. He was a learned Anglican theologian—a Master of Arts of the University of Oxford, and the parson of a rural parish in Buckinghamshire. He was an astrologer who told horoscopes. He was an alchemist, a mathematician, and a conjurer of spirits, using an archangel as a medium. He was, as Professor MacDonald claims, one of the last Renaissance magi, an expert in a whole series of now wholly discredited but at the time highly sophisticated and respected intellectual systems, Galenic, Rosicrucian, alchemical, Hermetic, cabalistic, Neoplatonist, and also Christian. To some contemporaries he was suspect as a “necromancer,” a “conjurer,” whose activities were challenged by the “piss-prophets,” the professional doctors with their urine specimens.

His eclectic notion of causation was soon to be dissolved in the light of the new Baconian scientific method, the new Newtonian scientific theory, and the new Latitudinarian and rationalist religious atmosphere of the post-Restoration period. The Reverend Richard Napier would not have fitted easily into the world of Samuel Pepys and King Charles II. He was a product of a specific period of history: one of home care rather than confinement, of amateurs rather than professionals, and of therapeutic eclecticism rather than pseudo-scientific medicine. He is important both as an exemplar of the intellectual climate of the early seventeenth century and also as a careful note-taker who opens a window for us on a hither-to unknown world, that of the humble, or not so humble, patients themselves, of whom this book deals only with those who were psychologically disturbed rather than physically ill. Napier’s clients were drawn from those classes able to afford to pay his modest fees of six to eighteen pence per consultation—that is, the top three quarters of the population, excluding the very poor. Half of them came from within ten miles, and almost all from Buckinghamshire or neighboring counties. They are thus a good sample of a rural population not too far from London.

The first surprise is how relatively few of Napier’s patients were psychologically sick. Today it is reckoned that about one third of all patients who consult some kind of medical practitioner are either overtly psychologically sick or suffer from some mental disorder that finds expression in physical symptoms. Only 5 percent of Napier’s patients, however, have been classified by MacDonald as suffering from mental as distinct from bodily illness. This suggests that the frequency of psychological illness in pre-modern societies may have been relatively low compared with those of the contemporary, modernized world. Nearly two-thirds of the psychologically disturbed patients were women. This was explained by medical theory, which recognized that physical disorders connected with the uterus, which they mysteriously called the “suffocation of the mother,” caused psychological symptoms.

Melancholia was the great affliction of the elite and intellectuals in the early seventeenth century, but Napier’s case-book shows that it was equally common lower down the social scale. Many women were plunged into depression by their oppressed lot as females in a patriarchal society, at the mercy of their parents or husbands. One-seventh of both sexes were disturbed by the threat of economic disaster, especially ruin and imprisonment for debt, which was an ever-present menace to the small shopkeeper and trading classes, in an age in which interest rates were high, price fluctuations and environmental hazards great, and insurance nonexistent.

Napier’s records shed a fitful light on problems of family history in the early modern period. A number of the mentally disturbed were troubled by the usual misfortunes of mankind, fear and jealousy, marital disputes, disappointment in love or marriage. Bereavement, however, did not loom large as a cause of anguish, presumably because it was so common. It was the cumulation of misfortunes that was too much. Take, for example, William Stoe, about whom Napier’s note runs: “Much grief from time to time. Had a wife long sick who died after much physic. Lost much cattle which died. Had the plague in his house: two children died [and he] himself had it…. Never well since.” The death of children disturbed a number of female patients, but it is noticeable that all the recorded cases are of children over the age of four. Infants died so frequently that few parents were seriously disturbed by their loss, but young children at their most bewitching age had a better expectation of life, and developed strong bonds of maternal affection. Napier thought it a sign of mental abnormality if a woman “careth not for her children. Can take no joy of her children.” But then she was so depressed that she was “tempted to hang herself.”

Frustrated love was a not uncommon cause of mental strain, even if few rejected lovers went as far as Thomas May: “Grief taken for a wench he loves. He sayeth if he may not have her, he will hang himself.” A significant number of the lower middle classes certainly fell in love in the early seventeenth century. But the problem left unsolved by these case studies is whether they represent a social norm of courtship and marriage for love, or are merely a small minority of eccentries who were bucking the system of arranged marriage for money. Did they themselves believe that to be lovesick was a form of madness? It is noticeable that about a sixth of those distressed by courtship or love were frustrated in their wishes by the adults, such as a young man who was prevented by his father from marrying his lover and “fell distracted.” Did a minority of the young fall in love but the majority obediently follow the advice of their elders? We still do not know. More were disturbed by cruel or drunken or diseased or otherwise unsatisfactory husbands, but this may have had more to do with day-to-day survival than with love itself.

Those who believed themselves bewitched by a neighbor were twice the number of those disturbed by frustrated love or marital mistreatment. Indeed, a third of all Napier’s mental patients thought they were bewitched, a statistic which throws a vivid light upon the degree of bitterness and malevolence prevalent in an early modern village. Professor MacDonald is one of those who believe that “hatred, fear and violence were endemic in rural England before the Industrial Revolution”—a view with which I wholly concur. It was a world of suspicion, intrigue, petty jealousy, sudden brawls, and vindictive revenges for assumed slights or injuries.

When it comes to analyzing the recorded symptoms of mental disease, vast chasms of incomprehension begin to open up between ourselves and the inhabitants of the seventeenth century. Robert Burton, with his scholar’s compendium of madness in The Anatomy of Melancholy, and Richard Napier with his practitioner’s notes of actual cases, are equally difficult to decode. Napier recorded his clients mostly as “troubled in mind,” “melancholy,” “mopish,” “light-headed,” in that order, running down through “senseless,” “grieving,” “weeping,” “frantic,” “distracted,” “furious,” to “solitary,” “suspicious,” or “wandering.”

It can be seen, however, that Napier’s universe of the mad contained two basic types. There were those with uncontrollable violent energy or mental incoherence, who might be a danger to others or be incapable of caring for themselves. And there were those who suffered from physical torpor and emotional delusions and disorder—those he characterized as “melancholy” or “mopish.” Only a tiny handful of his patients were defined by him as “mad” in the sense that they lacked all sense of the links between personal behavior and the norms of society. It was these, and these alone, whom the seventeenth century locked up, chained, and physically punished to try to bring them to their senses. Thus only twenty of the 2,039 mental patients who visited Napier had been either chained or beaten. It was persons like those who composed the twenty or thirty in Bedlam in 1700—who were visited by some 96,000 tourists a year. To contemporaries, madmen were men reduced to the level of animals, since they had lost the power of reason and thus their soul.

Both the patients and their learned advisers like Napier held one thing in common with modern man. Both believed that there is no rigid distinction between mind and body, and that the two interact upon each other. Thus a near contemporary of Napier, a more colorful and eccentric character called Simon Forman, who also ran a large consulting practice, diagnosed a woman in 1597 in the following terms: “Much subject to melancholy and full of fancies…. She hath not her courses, and the menstrual blood runneth in her head. And she thinks the devil doth tempt her to do evil to herself.”⁸ Whether Forman himself believed in the devil is not clear, but the huge number of Napier’s patients who thought themselves bewitched is proof of how widespread was a magical view of causation among the population at large. Napier’s eclectic treatment, which included magical amulets, Christian prayers, astrological horoscopes, and Galenic medicines, shows his own uncertainty about where the truth lay.

Professor MacDonald has written a remarkable and important book, distinguished both by the meticulous analysis of a vast and hitherto untapped body of source material and by a sophisticated presentation of the conclusions to be drawn about the social and mental world of early seventeenth-century England. In his concluding chapter he goes further, to peer beyond into the late seventeenth and eighteenth centuries, the age of the monopoly of treatment by the medical profession, and of increasing care in private madhouses. He sees two interlocking trends at work. The first, stimulated by the religious excesses of the English revolution, was a rejection by the elite of religious enthusiasm, and by extension of all religio-magical explanations of how the world worked. The theory that the devil was at work in the possessed or in witches was no longer regarded as credible. After the experience of the civil war, irrational systems of belief were seen as threats to the established social order, which the ruling classes were determined would never again be subject to such radical challenge. Religious zeal was now equated with “enthusiasm,” and regarded as a form of madness, while demonic possession was treated as mere delusion or hypocrisy.⁹ Suicide ceased to be regarded as a sin against the Holy Ghost, instigated by the devil, and to be punished by burial in unconsecrated ground and seizure of property. Jurymen now declared that suicides were non compos mentis. ¹⁰ “Reason” was now king, and since medicine was allegedly scientific, it was the medical profession that naturally took charge of the insane, and confined the worst cases, according to the prescribed rules of their profession.

Despite the total lack of any evidence of the practical effectiveness of curing the insane by purges, bleeding, emetics, and chains, professional medical theory fitted neatly into post-Restoration elite culture, compounded as it was of rational religion, neoclassicism, and natural philosophy. By now, Richard Napier and all his works were a hopeless anachronism, bypassed in the rush to supposed modernity.

Dr. Walker and Professor MacDonald have rediscovered an important but lost piece of the intellectual and cultural history of the West, one which offers a plausible explanation of the triumph of professionalism in the late seventeenth and eighteenth centuries, and the modest spread of private madhouses. These two studies fit these changes into the changing cultural patterns of an increasingly secular and optimistic age. This makes much more sense than attributing them to an evil conspiracy of the early modern bureaucratic state and professional elites to enslave the multitude.

Among the poor, however, the old system of semimagical beliefs persisted. Bacon himself had expressed skepticism about the efficacy of medicine, “a science which hath been more professed than laboured, and more laboured than advanced,” a point of view which opened the way to innovations in anatomy and chemistry. The poor, however, remained wholly skeptical, and a popular almanac for the year 1688 predicted that physicians “would all be busy killing sick people.” As a result of this conservatism, there emerged in the late seventeenth century a major dichotomy between elite and popular culture with respect to the efficacy of doctors and the treatment of the insane.

Nor were the poor altogether wrong in their rejection of the new order of things. Private madhouses were indeed often a public scandal, and it was not until 1774 that Parliament passed the “Madhouse Act” to set up a system of licensing and inspection. Foucault is almost certainly right to believe that confinement in the eighteenth century was a retrogressive step by which more and more of the mentally ill were subjected to the treatment hitherto restricted to the dangerous lunatics. Moreover it was now easy to abuse the services of private madhouses out of personal spite, and nothing was more common in the eighteenth century in a marital quarrel than for a husband to threaten to lock his wife up in a madhouse.

On the other hand, the great humanitarian movement of the late eighteenth century appeared to change all that; it provided the basis on which the state built larger and more elaborate asylums. The “moral” methods of leniency and kindly treatment were first introduced by William Tuke at the York Retreat in the late eighteenth century, and as a result the Victorians were convinced that the bad old days of medical mistreatment of the insane in madhouses were over. They reflected complacently on how in the eighteenth century “coersion for the outward man and rabid physicking the inward man were specifics for lunacy. Chains, straw, filthy solitude, darkness and starvation…; nothing was too wildly extravagant, nothing too monstrously cruel, to be prescribed by mad-doctors.” Nonmedical practitioners now tried to work on the mind rather than on the body, and by gentle rather than forceful methods—which was a direct challenge to the monopoly of treatment now claimed by the medical profession. The locus classicus of this great reform is the picture of Pinel striking the chains from the lunatics at Bicêtre in the middle of the Terror in Paris. Lunacy was now regarded as a curable disorder, given the right physical conditions and the right psychological treatment. Unfortunately, however, this optimism was unjustified, and the Victorian asylums slid imperceptibly back into holding pens for persons patently incurable. Attention of the well-meaning was therefore focused on the humane treatment of the inmates, rather than upon their cure.

There followed the rise of psychiatry as a profession to deal with the sick mind, an endeavor that has had only very limited success. Today, we are back to where we were in the seventeenth and eighteenth centuries, restoring the mind by treating the body with chemicals instead of purges and emetics, and electric shocks instead of whips and chains. Thanks to drug therapy we are also emptying the asylums, and releasing their inmates once more into the streets, where they had been up to the eighteenth century, before the great confinement began.

Some aspects of the nineteenth-century phase of these developments in the treatment of madness are illustrated in a useful series of essays about particular institutions and personalities edited by Professor Scull.¹¹ Over the entire collection, however, looms the brooding figure of Professor Foucault, whose creative, if pessimistic, imagination still dominates the field. One very serious result of the current mood of denigration of doctors and scientists is a downplaying of the crucial distinction between truth and falsehood. Some treatments of the insane used today seem to work; almost all used in the seventeenth and eighteenth centuries did not. It is one thing to overthrow the simplistic Whig interpretation of history, but another to put in its place an equally simplistic pessimism that seems unable to distinguish antibiotics or insulin from charms, prayers, or whips. The strength of the work of Walker and MacDonald is the sophistication of their interpretations and the close attention they pay to the sources. In their hands insanity becomes a window through which to observe fundamental changes in the intellectual and social life of the West, as rationality slowly took the place of faith, magic, and superstition. Whether this was a change for the better or the worse is, unfortunately, still very much a subject of dispute.