How can we reason about madness?

Madness was seen as something that was supernatural in early civilizations. For example, Assyrians and Egyptians saw diseases as coming from God, and thus healing was entrusted to priests. The Greeks also viewed madness as something that came from God. Later, Greek philosophers pointed to the cosmos and the human conditions as the cause of madness. Plato and Socrates stepped away from God as the cause, and instead analysed people’s psyche: reason, spirit, passion, and the soul. Aristoteles defined man as being a rational animal, within the system of Nature. Protagoras then pointed to ‘Man’ as the cause of all things. Thus, a lot of Greek philosophers reasoned about nature, society, and consciousness. They casted the ‘rational individual’ (educated males) as the basis for ethical and political ideas. They did not deny the reality of the irrational. Plato pointed to ‘appetite’ as the human enemy of freedom and dignity. His ideas were called ‘mind over matter’, became classical values in later philosophies. For example, Delphic stated that ‘know-thyself’ reasoning was important in analysing and explaining human nature. Irrationality became to be seen as a danger, and reason or the soul should combat this irrationality. Thus, Greek philosophers changed ‘madness from the heavens’ to ‘madness of humans’. How did these Greek philosophers suggest to cure madness?

How was madness medicalized?

Medicine complemented the theatrical and philosophical traditions that already existed. For example, Hippocrates, developed a holistic explanatory scheme for health and sickness, such as madness. He excluded the supernatural out of this explanation. Hippocratic medicine involved explaining health and illness in terms of ‘humours’, which were basic fluids. According to Hippocrates, the body was dependent on the dynamics of development and change within these fluids. When people got sick, this meant that their fluids were in imbalance. These fluids were called blood, choler (or yellow bile), phlegm, and melancholy. Blood was the main force behind vitality. Choler was a gastric juice, which was important for digestion. Phlegm was a broad category including all colourless secretions, such as sweat, and tears. When people were sick, and had a cold or fever, phlegm dominated according to Hippocrates. The last fluid, black bile or melancholy was the most problematic. It was a dark liquid and it was seen as the cause of darkening of other fluids, such as when blood or the skin became black. It was also seen as the cause of dark hair, dark eyes, and skin pigmentation. These fluids also influenced physical existence, for example temperature, colour, and texture. Blood lead to hot and wet flesh, choler made the flesh hot and dry, phlegm made it cold and wet, and black bile produced colour and dry sensations. These ideas were in parallel with Aristoteles’ philosophy, in which he thought of air, fire, water, and earth as the elements of the universe. Blood was like air, because it was warm, moist, and animated. Choler was like fire, because it was warm and dry. Phlegm suggested water, because it was cold and wet, and black bile resembled the earth, because it was cold and dry.

These humours were also used to explain temperaments, which were also called personality and psychology dispositions. Someone who would be dominant in ‘blood’, would also have a ‘sanguine’ temperament: lively, energetic, and robust, but also hot-bloodedness and a short temper. Someone who was dominant in choler or bile, may have high verbal abilities, same as people with high phlegm and black bile. Humoral thinking thus also explained how people shifted from healthy to sick, both in physical and psychological ways. When there was a good balance in the humors, everything was good. But, if this balance shifted, perhaps through a bad diet, then people became sick, and developed ‘sanguineous disorders’ (what we might now call high blood pressure). In terms of mental disorders, excessive blood and yellow bile could lead to mania, and a surplus of black bile could lead to lowness, melancholy, or depression. Thus, certain treatments of the sick involved blood-letting, and a change of diet. For example, madmen would be put on a diet containing greens, barley water, milk, and were banned from drinking wine and red meat. Thus, mental disorders arose from physical disorders.

What was the clinical gaze?

Thus, the humoral framework was not only abstract. It was full of practical treatments for the sick. Mental abnormalities were also the focus of Hippocratic writings. For example, there are reports of  a woman who was noted as having rambling speech and obscenities in speech. She also exhibits fears, depression, and grief. Another woman was very silent, and would not speak at all. The latter was described as melancholia. In the Greek medicine, there were two causes of mood and behavioural disturbance, namely mania and melancholia. Melancholia was seen as a mental disturbance, with anguish and dejection as its elements. IT also involved powerful emotions, such as hallucinations and sensations of mistrust, anxiety, and trepidation. Mania was a condition marked by excess and uncontrollability, and was described by ‘fury, excitement, and cheerfulness’. Someone suffering from mania could for example ‘slaughter the servants’ and feel grandiose. It thus often included euphoria: someone feels great, and inspired. There was also mania that involved the idea of being possessed by a god. For example, people suffering from this ‘divine furor’ would sometimes even castrate themselves and offer their penis to the goddess. Arateus came up with bipolar disorder. This entailed that some patients, after being melancholic have mania, and after the mania, they may become melancholic again.

A continuing tradition?

Islamic and Christian medicine follow the medical traditions of Hippocrates, which was systematized by Galen, Arateus, and others. Diagnoses of melancholia and mania dominated the diagnoses in this medicine. Later, Bartholomeus Anglicus, expanded ‘melancholia’ with states of ‘anxiety’, ‘hypochondriasis’, ‘depression’, and ‘delusion’. Also in the Renaissance Greek thinking remained stable. For example, Denis Fontanon described mania as ‘it occurs sometimes solely from the warmer temper of the brain without a harmful humour, and this is similar to what happens in drunkenness. It occasionally arises from stinging and warm humours, such as yellow bile’. He also addressed the varieties of mania. For example, it was good when mania involved laughter, but when there was a mixture of blood and choler, mania would turn into ‘ brutal madness, and the most dangerous form of mania’. Felix Platter described melancholia as leading to ‘imagining, judging, and remembering things falsely’. Maniacs would ‘do everything unreasonably’. Platter also emphasized anxiety and delusion in his descriptions of melancholia. He says that ‘it is a kind of mental alienation, in which imagination and judgement are so perverted, that without any cause, the victims become very sad and fearful’. Timothie Bright, another contemporary writer, published the first English writings on melancholia in  1586. Shakespeare’s writing about psychiatric problems probably were based on these writings of Timothie Bright. However, the humoral approach came to a peak after Robert Burton’s ‘Anatomy of Melancholy’. Burton described melancholia similar to Hippocrates, but he added different causes or antecedents of the condition, namely ‘idleness, solitariness, overmuch study, passions, perturbations, discontents, cares, miseries, vehement desires, ambitions’. According to Burton, marriage was the best remedy for melancholy maids. He also suggested music therapy. Burton said that he was himself a sufferer of melancholy, he states: “I wrote of melancholy by being busy to avoid melancholy”.

How did these ideas go into psychology?

In the seventeenth century, the mind became prominent in the philosophical models of man. For example, René Descartes stated that reason was the only thing that could rescue mankind from falling into ignorance, confusion, and error. Descartes dedicated his life to the pursuit of truth. He built on himself, saying ‘Cogito, ergo sum’, which means “I am thinking, therefore I do exist”. Descartes felt like Ptolemaic/Aristotelian thinking should be replaced by a new philosophy, which was grounded in reality. Thus, a philosophy that was composed of particles of matter in motion, which obeyed mathematical laws. Therefore, he created a distinction between matter and mind. Matter is extension from the mind, so the body is also ‘matter’. According to Descartes, humans possessed minds, but animals were mere matter and motion (and thus machines). Descartes also introduced reflexes in his account of the nervous system. He also equated the mind to the soul. But, it was immaterial, and thus had no location in space (no extension in space). But, the mind was thought to emerge in the pineal gland, which was a structure in the middle of the brain. Later, after Descartes died, researchers pointed to different areas of the brain such as the medulla oblongata, the corpora striata, and the corpus callosum. These were then seen as the true seat of the soul.

Thus, Descartes clearly revolutionized philosophical thinking and medicine. However, he was unable to respond appropriately to the question: “how do mind and body interact?”. This is called the mind-body problem, which still exists in contemporary times. Materialists were inspired by Descartes, even though Descartes was not a materialist. Materialists went further than him, and denied the reality of anything at all, except for matter. Thomas Hobbes was one of such materialists, and was the greatest enemy of orthodox Christians. According to Hobbes, the universe was only matter, and there were no spirits, and no God. According to Hobbes, knowledge derived from sensations, and behaviour was determined by physical laws of matter in motion. Emotion was according to him, only motion. According to him, religion was a form of delusion. Insanity was thought to occur because of some defects in the body. John Locke, in his ‘Essay Concerning Human: Understanding’, supported these ideas, and claimed that all ideas originate from sense impressions (taste, sight, touch, hearing, smell). The mind is initially a blank sheet (tabula rasa), which is shaped by experience and nurtured by education. According to Locke, witches and goblins are false beliefs. Madness was also a delusion. According to Locke, ‘Mad men put wrong ideas together, and make wrong propositions, but argue and reason right from these ideas. But, idiots make very few or no propositions, but argue and reason scarce.” This Lockean thinking formed the basis for new secular and psychological approaches to understanding madness, or insanity. According to Locke, madness could be treated by thinking appropriately. Thus, among the 17th century philosophers, madness was not associated with demons, humours, or passions, but with irrationality. However, mental disorders remained to be mysteries.