Madness in the Middle Ages

Authored by: Claire Trenery , Peregrine Horden

The Routledge History of Madness and Mental Health

Print publication date:  April  2017
Online publication date:  April  2017

Print ISBN: 9781138781603
eBook ISBN: 9781315202211
Adobe ISBN: 9781351784399

10.4324/9781315202211.ch3

 

Abstract

Different people held different views as to what the disease . . . was. Some said it was a kind of great frenzy. Others claimed he was possessed by a demon. Now there were some indications of both these afflictions, but nonetheless I always heard that never once in the whole course of his illness did he want to injure anyone except himself. This is not what one hears about the frenzied or the possessed. 1

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Madness in the Middle Ages

Introduction

Different people held different views as to what the disease . . . was. Some said it was a kind of great frenzy. Others claimed he was possessed by a demon. Now there were some indications of both these afflictions, but nonetheless I always heard that never once in the whole course of his illness did he want to injure anyone except himself. This is not what one hears about the frenzied or the possessed. 1

The sufferer here was the great Flemish painter Hugo van der Goes (1433/40–1482). He entered a religious house near Brussels in 1477 and his case was reported, decades later, by one of the brethren, Gaspar Ofhuys. Hugo had recently completed the major commission of the ‘Portinari altarpiece’ for a hospital church in Florence. He included in the picture a symbolically charged array of flowers, all related to religious healing, and among them a sprig of black columbines in a jar – melan being the Greek for black, anacolie being columbine in French – as if he was praying for release from melancholy. 2 That may have been a premonitory sign of the condition that came to a head a few years after Hugo entered the religious house. On a visit to Cologne he succumbed to ‘a strange disease of his cognitive [or imaginative] faculties’ (as Ofhuys puts it). He repeated that he was eternally damned and tried to kill himself. When those travelling with him returned to Brussels, they summoned the prior. He thought that Hugo had the same affliction as Saul, an unclean spirit, and he therefore applied the remedy of David (who played his harp). He arranged some music therapy before Hugo rejoined the brethren, among whom no instrumental music was allowed. It did not work.

Ofhuys worries away at Hugo’s diagnosis, deploying a respectable degree of medical learning (for which, doubtless, he had been made monastic infirmarer). While God alone knew the truth, he thought there were two possibilities. The first was that the condition was natural, arising from melancholic foods; from strong wine; or from an emotional excess, of anxiety, fear or sadness. Hugo accepted too many commissions, which made him anxious, and drank too much with his patrons. Some thought indeed that his anxiety had been so great as to rupture the particular delicate vein in his head that nourishes imagination and fantasy. A second possibility was divine providence. Hugo had been puffed up by the grandeur of his guests and by the exalted status within the order that his skill as a painter brought him. God sent him this affliction as a humiliation and penance, not to kill him, but to save him from torment in eternity.

For neither Ofhuys nor his readers would any of those possibilities – physiological (diet), psychological (morbid imaginings), possession by a spirit or demon, divine providence – have been seen as mutually exclusive. Illness was conceived by the medical authorities of his time as genuinely psychosomatic, in terms of a two-way traffic between soul and body. Demons made their way the more easily into a physically disordered person. God used body and soul as means of chastisement and correction.

Very few ‘mad’ people other than saints and rulers are known to us as named individuals with biographies from the Middle Ages. That is why even so abridged and heavily moralizing a text as Ofhuys’s chronicle is precious. It is, incidentally, the only documented medieval European case of music therapy practised rather than just recommended. More broadly, it shows the hesitations over definition and diagnosis that were probably a feature of so many encounters with those whose utterances and behaviour confounded normality. It also brings out the inseparability of religious and medical responses, and the extent to which a naturalistic diagnosis of madness was always possible, even within a milieu such as a monastery that was well accustomed to the demonic.

The historiography of medieval madness, which it is the aim of this chapter to exemplify and survey, has taken some time to come to terms with cases such as Hugo’s – even though the painter’s art and character have long attracted specialist attention, and even though scholarly and wide-ranging monographs on medieval ‘folly’ or ‘madness’ have been appearing for decades. The older studies of the 1970s, followed by a further clutch around 1990, brought together law, theology, religious practice, medicine, vernacular literature, and various other kinds of evidence. They have not been superseded. Some were perhaps too much in thrall to Foucault, some engaged in too much retrospective diagnosis, some were too anecdotal or relied on questionable secondary material. Their greatest problem, however, was the lack of a context in medical, religious and social history to enable them to knit together the data provided by each kind of evidence into any overarching narrative. We still do not know how to do that. As the field has grown, so it has, not surprisingly, fragmented. Synthesis lies even further beyond the horizon than it did in 1990. 3

The way into this complex field that we have chosen is through the broad intellectual setting: ideas about insanity that were most widely diffused and that help us to understand at least some of the commonest reactions to cases of madness. We shall move though medical and religious considerations before turning to legal provision for the insane in the community and the question of hospitalization. We shall then look to literary representations before ending (as we began) with some well-known mad individuals. As a postscript, we add a brief section that looks eastwards.

The aetiology of madness

Madness, unreason, and the Christian mind

Aristotle held that what separated the soul of man from the souls of animals was man’s possession of reason and intellect. 4 This idea resonated with later Christian writers who were interested in the role that man’s reason played in his relationship with God. One of the best-known biblical cases of madness – that of Nebuchadnezzar – encapsulates this relationship between reason and madness, man and beast, and divine favour and punishment (Daniel 4:1–37). 5 Understanding the role of the mind was vital for theorists contemplating Christian spirituality and practice, and discussions of the mind and the soul feature prominently in Christian philosophy. E. Ruth Harvey has examined the relationship between philosophical and medical teachings on the nature of the body and mind. 6 She argues that

because of the ambiguous nature of the bodily spirits, which both partook of the physical constitution of the body, and provided the link by which the mind communicated with the bodily organs, the doctors were led to the treatment of disordered reason almost as though it were a purely physical function; whereas the philosophers insisted that reason as such fell outside medical control. 7

A study of medieval madness requires an analysis of contemporary understanding of body, mind, and ‘bodily spirits’. Not only does such understanding elucidate medical theories of madness; it is a necessary primer to considerations of Canon Law. Harvey demonstrates, moreover, that the essence of subsequent debates penetrated beyond the spheres of philosophy and medicine into literature and folklore. 8 The concept of the ‘bodily spirits’ – Harvey’s ‘inward wits’ – influenced and permeated perceptions of, and approaches towards, madness. Their origins in philosophy and medicine emerged from considerations of the mind, connecting philosophical teachings on the mind with madness. Christian theology of the mind has been studied extensively by historians, though it is rarely connected with madness, largely because ancient and medieval philosophers themselves seldom focused on madness specifically. 9 It is thus worth briefly examining the origins of medieval philosophies of the mind before moving on to investigate theories concerning madness itself. 10

The medieval concept of ‘bodily spirits’ can be traced back to the Stoic school of the fourth century bc, which was influenced by Aristotle. An answer was needed to the question of how the material body was made physically animate under the control of the immaterial soul. The explanation offered by Stoic philosophers was that the soul operated through the agency of pneuma (spiritus in Latin), or bodily spirits. These animating spirits could be witnessed by the physician in the air that was breathed in and out of the body. Pneuma was material, but its form was finer than that of other elements, allowing it to express the soul’s intentions through the physicality of the body. The Stoics placed the source of pneuma in the heart (the hydraulic model), but Hippocratic thought located it in the brain, and connected it with the three faculties of imagination, reason, and memory.

The hydraulic model of the mind and its influence in Anglo-Saxon England is the subject of Leslie Lockett’s book Anglo-Saxon Psychologies, in which she examines both metaphorical and literal applications of cardiocentric psychologies in Anglo-Saxon vernacular and Latin writings. 11 Lockett traces the development in Ancient Greek epic, Aristotelian philosophy, and Biblical narrative of the localisation of reason and emotion in the organs of the chest and abdomen. 12 She draws attention to the fundamental discussion of the relationship between body, mind, and soul, and the strong connection between all three in the hydraulic model, which denied the total incorporeality of the soul because of its physical association with specific areas of the body. 13

The increased circulation of Patristic texts from the eighth to ninth centuries onwards brought to prominence the Augustinian model of the soul, as an incorporeal entity, without physical location, and possessing the faculties of reason. 14 This raised crucial questions regarding the moral implications of madness in the soul and the ability of mad individuals to engage with the Christian community. Thomas Aquinas, whose philosophical writings were widely circulated in the later Middle Ages, contemplated the participation of the mad, as members of a Christian society, in Christian worship. There were circumstances – such as the imminent likelihood of fatality – in which the mad, especially those who had not been mad since birth and had previously consented to baptism, could be baptized. Mad men and women, Aquinas argued, were members of the Christian community because, unlike irrational animals, they possessed rational souls, but had lost the use of their reason through bodily impairments. 15 Likewise, the Sacrament could be given to those who had lost their reason but had formerly shown devotion towards the host. 16 It seems that the inability to express devotion through one’s rational faculty did not mean that the incorporeal soul could not benefit from the Sacrament.

Nonetheless, whilst the human soul was incorporeal, it was certainly not incorruptible, and could be led astray either by the passions of the physical body, or through the temptation of demons. From as early as the fourth century, one particular condition of the brain’s faculties was associated with spiritual impairment. Acedia was related to melancholy; the two conditions were differentiated by the presence of delusions in melancholic patients. 17 Acedia was initially thought to be exclusive to anchorites (those who had chosen a solitary religious existence in the harsh landscape of the Egyptian desert), but later it was a diagnosable state of mind affecting mostly monks and nuns. Stanley Jackson suggests that the ‘condition was characterized by exhaustion, listlessness, sadness or dejection, restlessness, aversion to the cell and the ascetic life, and yearning for family and former life.’ 18 Acedia was sometimes associated with the sin of sloth, and the necessary treatment for this was confession, but it could also be attributed to excess phlegm or black bile in the rational faculty and could supposedly be eased with relaxation and music. 19 Undesirable behaviour could be connected with a problem in the brain and, crucially, could require both physical and spiritual treatment.

Medical approaches

Historical considerations of medieval madness as a medical condition are generally found within larger studies of medieval medicine or within broad overviews of madness. In-depth studies of individual conditions – such as Mary Wack’s work on lovesickness and Amy Hollywood’s analysis of melancholia – have striven to place specific medical conditions within their social contexts. 20 Luke Demaitre’s volume on Medieval Medicine examines conditions in a head-to-toe format, based on that commonly adopted by medieval medical writers themselves. 21 Demaitre dedicates a chapter to conditions of the head, which, in the medieval medical manuals known as practica, included discussions of ‘the hair, the skull and brain, mental function, and motor control’. 22 However, as Demaitre himself concedes, such medieval conditions cannot be easily divided into the modern categories of psychological and neurological complaints. 23 To understand medieval conceptions of madness, we have to consider what influenced medical ideas.

There is some evidence for the dissemination of learned medical theories in the Christian west prior to the eleventh and twelfth centuries, but the rise of university-based medical learning in the High Middle Ages brought with it a plethora of theological and practical medical manuscripts. 24 Monica Green is compiling a list of Latin medical manuscripts in circulation in the twelfth century, and notes 375 codices, totalling at least 145 distinct texts, in her 2009 article. 25 Some works of the great medical writers of antiquity – Hippocrates and Galen – had been translated into Latin as early as the sixth century, but scholarly interest in their theories was renewed in the eleventh century in and around the medical schools of Salerno. 26 As Salerno’s reputation grew, its medical texts were widely circulated amongst European universities and monasteries, with the humoral model forming the basis for discussions of health and sickness. The body’s functions were believed to be reliant on four humours and their associated qualities: blood (hot and wet); yellow bile or choler (hot and dry); black bile (cold and dry); and phlegm (cold and wet). These humours needed to be regulated (for example, by diet) in order to maintain a natural state of health. Imbalances in the humours led to what modern practitioners would classify as physical and mental health conditions. Treatment for these conditions consisted of various methods to restore humoral balance.

One of the most famous and widely circulated medical encyclopaedias of the later Middle Ages was the Canon of Medicine by the Persian physician known in the West as Avicenna. Originally compiled in the early eleventh century, the Canon was translated into Latin in the twelfth century and became a standard medical text for most university physicians. According to Avicenna, the substance of the brain was cold and moist. 27 Following humoral principles, its stability could be damaged by an excess of heat or dryness. The location of this damage determined the nature of the brain condition and its symptoms. The simplest model of the brain divided its material substance into three parts. The imaginative faculty, located at the front of the brain, processed the information received by the senses, hence its proximity to the sense-receptors of the face. This information was passed on to the central brain faculty, rationality, which formed it into concepts and judgments. Memories were stored at the back of the brain, as images literally imprinted on the wet matter. 28 Mental illnesses were caused by humoral or anatomical abnormalities in one or more of these three areas. For example, amnesia indicated a problem in the memory faculty, such as the rising of hot vapours to the back of the head, which interfered with the storing of images. 29

Madness, or amentia/insania in Latin, was not often discussed as a distinct condition in medical manuals. Instead, it could be symptomatic of other conditions, or it was used as a generic term for illnesses of the imaginative and rational faculties that affected the cognitive functions of the brain. The three main conditions that were associated with madness in medical texts were frenzy (frenesis), mania (mania), and melancholy (melancholia). Precise symptoms and healing techniques varied slightly from writer-to-writer but those found in the Pantegni – a theoretical and practical medical manual translated from Arabic into Latin in the late eleventh century and widely circulated in western Christendom from the thirteenth century – are indicative of commonly held beliefs. Frenzy was caused by a hot brain abscess, most often comprised of yellow bile, which upset the natural coolness of the brain. 30 Primarily affecting the imaginative faculty at the front of the head, the face and head would usually become warm to the touch. Sleep was disturbed and the patient could awaken in the night, screaming. In this state of unrest, the patient was prone to bouts of inexplicable laughter or crying and breathlessness. 31 Treatment relied upon the medieval principle that opposites cure; thus the coolness of the brain could be restored by lowering the temperature of the head. One technique was to shave the head and drench it in water or oil. If the patient’s general health allowed for it, the artery to the head could be phlebotomized in order to draw hot blood away from the brain. 32 There has, to date, been no full-length historical study of medieval frenzy – although Danielle Jacquart has explored the Greek and Arabic traditions – and more research would greatly benefit our understanding. 33

Both mania and melancholy were chronic conditions. Mania was characterized by frantic behaviour. 34 It was associated with stupor of the mind, a condition also connected with frenzy. 35 Gariopontus, an eleventh-century Salernitan physician, noted that the symptoms of madness could be similar in both conditions, but explained that maniacs lacked the fever from which frenetics suffered. 36 Physicians observed that, because the symptoms of mania often seemed inexplicable, the condition could be associated with demonic or divine activity. 37 One theory put forward by medical writers themselves was that mania was the result of an excessive diet, and thus purgatives that would induce vomiting or sweating were used to restore humoral balance. 38

Melancholy could also result from humoral imbalance. Excess black bile in the form of a vapour could rise from the stomach to the brain, affecting a patient’s understanding in the rational faculty. Melancholic patients were often sad and suspicious, and their inability to rationalize the world around them left many in a worrying predicament. 39 Hallucinations and delusions were common, with some patients barking like dogs and others crowing like roosters. 40 Various herbal remedies could be applied with the intention of restoring humoral balance to the patient through purging. 41 In his assessment of medieval understandings of melancholy, Jackson stresses that whilst both relaxation and, at the other end of the spectrum, binding were used for melancholic patients, these did not always constitute cures in themselves; entertainment provided a distraction and lightened the mood, whereas binding prevented a patient from hurting himself and others whilst treatment was ongoing. 42 Fernando Salmón argues that medical treatments for madness relied very much on the physician’s interaction with the needs of the patient; thus, for a melancholic who believed she was headless, a lead helmet was provided to give some psychological comfort. 43

Evidently, such conditions as frenzy, mania, and melancholia were difficult – and sometimes dangerous – to treat. It is difficult to know how successful the cures outlined above would have been and whether or not physicians actually applied them. Constantine was careful to make sure that the herbal remedies he recommended to treat melancholy were fairly simple for the physician to prepare, which perhaps indicates an expectation on his part that such treatments would be attempted. 44 Modern scholarship has suggested that, as early as the twelfth century, learned medical ideas were disseminated outside the university and university-based physicians, specifically to monastic communities who almost certainly had access to medical practica in their libraries. 45 Evidence of medical terminology can be found in hagiographies and miracles collections of the later Middle Ages, which proposed medical diagnoses for sick pilgrims who travelled to saints’ shrines hoping for miraculous cures. The miraculous cures of many mad pilgrims were recorded at shrines, and these records did sometimes refer to medical ideas, though with notably less frequency than was the case for other conditions. 46 Leigh Ann Craig has suggested that a ‘constructed diagnostic uncertainty’ was applied by miracle compilers specifically to avoid clarifying the cause of madness. 47 Multiple theories coexisted regarding the nature of madness, and to advocate a humoral diagnosis may have resulted in the exclusion of other theories that were equally regarded and well-established. The synchronicity of various models of madness in the Middle Ages is further exposed below by a study of practical provisions for the mad, and of literary and artistic portrayals of madness.

Demonic possession

As the case of Hugo van der Goes demonstrates, states of unreason, and even medical conditions, like frenzy, could be connected with demonic interference. Catherine Rider has shown that many medieval physicians themselves were willing to admit the possibility of a demonic aetiology for madness. 48 The often spectacular descriptions of demonic possession from the Middle Ages have attracted historians to this phenomenon, which was associated by contemporaries, like Aquinas, with impairments of imagination and reason. 49 Nonetheless, it is important to treat such accounts of demonic possession with caution. Was possession the same as madness, and in what ways were demons believed to influence physical and cognitive function?

Following Augustine, earlier writers stipulated that, whilst demons had no ability to enter the soul of a human, they could enter the body and manipulate the mind, either by confusing the imagination with erroneous images, or by impairing reason so that the victim was unable to comprehend the information received by his/her senses. 50 As interest in the human spirits grew from the twelfth century onwards, so too did attention to the movements of demonic spirits in the natural world. Nancy Caciola has examined the discernment of spirits (the process by which demonic spirits were differentiated from divine spirits) and its development in the later Middle Ages. 51

In hagiographic records (saints’ Lives and collections of the miracles performed by saints at medieval shrines), distinctions were not always made between demonic possession and madness. 52 As was the case with madness, signs of demonic possession included wild gestures, violence, twisted facial expressions, and shouting. 53 Signs more typical of demoniacs were abnormal powers, convulsions, blaspheming, abhorrence of sacred objects, and aggression. 54 Madness, especially violent madness, could be associated with demonic interference. The language of possession – that victims were ‘seized’ or ‘tormented’ by demons – illustrates the violence with which this affliction was connected. 55 From the thirteenth century, ‘madness was becoming naturalised’, and the language of demonic possession became less prominent. 56 Nonetheless, despite the waning use of demonic terminology in official records, there is still evidence of widespread belief in demonic influence over the mind: canonization dossiers recorded that those cured of madness had believed that they were possessed. 57 It is important, when considering medieval perceptions of madness, to acknowledge that ‘the medieval period witnessed great diversity of belief in the sphere of the natural and the supernatural’. 58 Demonic and humoral explanations for madness were not mutually exclusive, and the precise aetiology of cognitive malfunction was often difficult to discern.

Provision for the mad

Medieval law

For the best-preserved legal records from medieval Europe, historians have turned to England, and some headway has been made with understanding the legal position of the mad there. Naturally, a discussion of madness and the law is limited by the source material available, which notably focuses on the everyday legal standing of the landed insane and on the legal treatment of the criminally insane. Mad men and women who had no possessions and who had not committed a crime were far less likely to enter the legal record. In England, the survival of legal material from the post-Conquest period is far more plentiful than from its Anglo-Saxon predecessor. Nonetheless, Nigel Walker proposes that the Anglo-Saxon state offered leniency and protection for mad offenders, provided that it could be proved that a felony had not been committed during a lucid interval. 59 Stefan Jurasinski challenges this thesis by drawing attention to the absence of leniency in cases of mad suicide, and by suggesting that, whilst the mad were to be pitied, they were often deemed responsible for their actions, which, though beyond their present control, may have resulted from past sin or illicit demonic activity. 60 Alexander Murray looks in detail at the legal status of medieval suicide, concluding that, in cases of suicide by the mad, verdicts were far from consistent. Technically, a suicide committed without the conscious knowledge of the perpetrator was not a felony, but it was very difficult to establish the mental state of the dead perpetrator. Nonetheless, establishing the nature of a suicide, criminal or otherwise, was vitally important, because a criminal suicide could not bequeath possessions to his/her heirs and could not receive a Christian burial. It is for this reason that mad suicides feature in the legal record, and yet Murray has demonstrated startling contradictions in the application of verdicts and punishments. 61

Sara Butler considers the potential “leniency” of the insanity defence in medieval England. 62 In her sample of 192 criminal cases, taken from eyre rolls and coroners’ rolls from thirteenth- and fourteenth-century England, Butler finds only 15 attributed to demonic activity (mostly suicide cases), whereas the vast majority of cases described violent madness (frenzy or fury). 63 Medieval juries recognized these forms of madness as an ‘illness’, and rarely mentioned sin or any fault on the part of the sufferer as a contributing factor to this illness. 64 Alexandra Pfau has found that a similar state of affairs existed in medieval France, where officials were wary of prosecuting mad offenders, who were barred, because of their lack of understanding, from bringing cases to court and from acting as legal witnesses. 65 Wendy Turner has also investigated the ‘legal diagnosis’ of madness. 66 She argues that cognitive capability could be gauged by a memory test (where the subject was asked questions about his/her family, community, and daily activities). Juries would also consider whether or not a person’s ‘emotional’ reaction was appropriate to the situation in which they found themselves. Laughing whilst committing or recounting a violent crime, for example, was, understandably, deemed inappropriate. 67

Turner has also reflected upon the social implications of the legal provisions for madness in High Medieval England, looking predominantly at the care and custody of the landed insane. 68 The mad were predominantly cared for by their families or communities, and the wardship of a mad landowner was given to a guardian. Care was taken to preserve the landowner’s interests by ensuring that the guardian was not a direct heir, but this did not mean that the system was immune to exploitation by profit-seeking guardians who could take the revenues from their ward’s lands. Kate Parkin, in her investigation of 47 cases of idiocy (a term usually applied to those who had been mad since birth) in the Inquisitions Post Mortem between 1399 and 1447, found that the provisions for mad landowners were based more on custom than on written law codes. 69 Furthermore, families would sometimes attempt to hide an heir’s idiocy in the hope that they could avoid jurisdictional interference and simply restore the line of inheritance when the idiot died. 70 In Parkin’s words, legal provision for the mad was a ‘flexible process’. 71

Canon Law, the Papacy, and Christian morality

Colin Picket’s synopsis of madness in Canon (Church) Law, although written for the priest and not for the historian, is a fair starting point for understanding the complexities of ecclesiastical provisions for madness (demonic possession is excluded from his study). 72 Naturally, stipulations did not remain static throughout the Middle Ages and Picket provides a historical overview prior to his canonical commentary. 73 For the purposes of this chapter, it will suffice to summarize the areas of Canon Law in which some consideration of madness was necessary. The question of whether the mad could receive the Sacraments was much debated. Such reception was largely dependent on the past faith of the mad person. For example, a mad person could be baptized so long as others bore witness to his/her previous devotion. 74 Similarly, while a mad person could not enter into a contract of marriage, a marriage contract that had been made when both parties were sane remained valid if either party became mad. 75 Consent was crucial to the partaking of the Sacraments; whilst the mad were not capable of giving consent, previous consent, if proven, was sufficient. There was, however, a concern that those who had been mad since birth had never possessed the ability to consent to baptism. There was some disagreement over this issue but the consensus seems to have been to place the life-long mad in the same category as infants; they could be cleansed of original sin but, as they did not possess the reason to commit further sins, penance was redundant. 76 Following the same line, mad criminals were to be given a lesser penance upon recovery of their senses; some atonement had to be made for their crimes but it was acknowledged that, without the capacity to reason, their actions had likely lacked criminal intent. 77

Despite the biblical connections between sin and madness (Nebuchadnezzar), it does not seem that Church authorities specifically categorized madness as resulting from sin. Jerome Kroll and Bernard Bachrach call into question the medieval association between sin and madness, arguing that the attention that modern historians have given to this explanation of illness is a result of modern society’s desire to paint the medieval period as comparatively backward in terms of psychological knowledge and care. 78 In their study of pre-Crusade saints’ lives and chronicles, in which they define mental illness broadly to include madness, epilepsy, possession, and drunkenness, Kroll and Bachrach find that a relatively small percentage of mental illness cases were attributed directly to sin. 79 Those that were often stemmed from a desire on the part of the author to discredit the sufferer, for example, for his/her rejection of the power of a saint. 80 Madness could thus be used by Christian writers to make a moral point, but the condition was not perceived in a universally negative light. 81

Sabina Flanagan has more recently explored the Church’s stance on heresy in relation to madness. Canon II of the Fourth Lateran Council (1215), which dealt with Amalric of Bena, a French theologian whose theories were deemed heretical, specifically stated that Amalric’s writings were not so much heretical as mad, and Flanagan concludes that, in the eyes of the Church, madness seemed a lesser transgression than heresy, and could even be used as a defence against a charge of heresy. 82 In her subsequent examination of the relationship between madness, heresy, and the Devil, Flanagan points out that multiple theories existed on this subject at the turn of the thirteenth century (as they would in the time of Hugo van der Goes), and that many contemporary observers found it difficult to distinguish between humoral madness, demonic madness, and madness as a cover for heresy. 83 There was, however, a suspicion that madness could be feigned, which led to a tightening of regulations concerning it and heresy. 84

Hospitals

How much space did those labelled mad or foolish from birth find in institutions? A good many of the diverse foundations in medieval Europe that we can group under the heading of ‘hospital’ specifically excluded the insane, along with pregnant women or the acutely ill. Care of these was beyond their resources. It might also corrupt the liturgical and sacramental life that, throughout the Middle Ages, lay at the heart of such institutions.

Only towards the end of the period did hospitalization of the insane become more widely acceptable. But even in the late fifteenth century the facilities for the mentally ill in the most medicalized and best-endowed European hospitals remained rudimentary. At Santa Maria Nuova in Florence, a harbinger of the modern hospital in its medical staffing if ever there was one, the insane were simply chained up in a cell and purged or given the occasional sedative. ‘We have set apart another place for those who have lost their minds through illness, where they are kept in chains.’ 85 This brief notice, in a version of the hospital statutes prepared in order to impress Henry VII of England, follows pages of detail about how the other, physically sick patients are to be received and treated. It suggests a regime little different from the fetters and chains found in the more famous mad hospital of ‘Bedlam’ during a visitation earlier in the fifteenth century. 86

An older historiography would place the turning point to even this basic level of management in fourteenth to fifteenth-century Spain. 87 It locates the stimulus to change in the arrival of Islamic hospitals (later than elsewhere around the Mediterranean and Middle East as we shall see below), which had long evinced a much stronger tradition of functioning as asylums for the mad and placing them under medical supervision. Yet there is some evidence of mad people in hospital-like institutions from well before any Islamic evidence could be invoked to explain the acceptability of this type of care. 88

Literature and art

Literary criticism of medieval representations of madness is richly endowed, and takes a broad approach to the term ‘madness’. 89 Stephen Harper has highlighted the dangers of ‘applying the theological conventions of madness to all medieval literature works both to homogenize and to oversimplify the picture of madness in the Middle Ages’. 90 Like the historian, the literary scholar must bear in mind that few medieval writers conformed unerringly to the models of madness outlined above. The literary renderings of madness discussed here are not patterns to which every text can be made to conform; instead they are influential tropes that illustrate aspects of madness that have been identified by critics and could be interrogated further.

Penelope Doob classifies three popular literary portrayals of madness as ‘the Mad Sinner’, ‘the Unholy Wild Man’, and the ‘Holy Wild Man’. All three, she argues, were influenced by the popular biblical figure of Nebuchadnezzar whose madness inspired many later literary depictions. 91 Nebuchadnezzar’s sin and ultimate redemption informed constructions of madness as both a punishment and a spiritual therapy, which in turn illustrated God’s agency in the world. Harper extends Doob’s thesis by arguing that alongside traditional precedents, medieval writers were also influenced by the contemporary setting of their text, thus allowing spiritual and humoral explanations of madness to co-exist. 92

In her study of madness in French literature, Sylvia Huot explores literary madness as a form of ‘otherness’, which triggered various responses, including ‘fascination, fear, laughter, pity, and revulsion’. 93 Huot uses this starting point to unravel the role of the literary madman/madwoman, who could both be employed as a figure of comedy and as a vehicle of tragedy. 94 She also discusses the function of ‘madness’ as a literary metaphor for ‘death’. 95 The mad character ‘dies’ a symbolic death and a new identity is constructed for him/her, which allows the narrative to take a different trajectory (consider Tristan, Lancelot, Yvain). 96 This was a common trope in Arthurian literature. Madness could be used as a form of redemption for the mad character who, after alienating himself/herself from society, was able to find spiritual renewal. 97 Renée Curtis has explored the role of feigned madness in this process. 98 Madness, even when feigned, resulted in rejection from human society, and thus could act as a moral punishment and a means by which the character could reconnect with God. 99

The dual concept of madness as both a moral punishment reducing the sufferer to the status of a beast, and, at the same time, a form of spiritual redemption is further expressed in medieval art. Doob highlights the popularity of Nebuchadnezzar, who represented both facets, and whose image was widely repeated. 100 Caciola argues that artistic depictions of demonic madness also followed ‘scriptural precedent’ by portraying the wildness of demoniacs (loose hair, torn clothes) and the physical occupation of a demon, which was often shown entering or leaving a victim through his/her mouth. 101 Aside from the physical presence of a demon, Sander Gilman has explored how else the mad and the possessed were physically identified in literature and art. Like Huot, Gilman argues that the mad were typified by ‘otherness’ and thus required some form of physical marking to distinguish them. This distinction could be shown in a wild appearance (lack of clothes, hairiness), the carrying of a staff, or a hunched stance. 102 In the later Middle Ages, the isolation of the mad, and the tempestuousness of their minds, was shown in the Ship of Fools, an image that endured into the Early Modern period and typified the anarchy of madness. 103

Notorious madmen and madwomen

Aside from the great figures of literature (and Hugo van der Goes), it is difficult to engage individually with mad people of the Middle Ages. Nonetheless, a few distinguished individuals are well-documented and provide important case studies.

Margery Kempe, 1373–1458

Since the rediscovery of the Book of Margery Kempe in 1934, historians have been particularly interested in using this text to explore medieval connections between madness, divine inspiration, and mysticism. 104 Although narrated in the third person, the Book is widely held to be the first autobiography written in the English language. It relates Margery’s spiritual journey beginning with an episode of madness. 105 Kempe described her madness as an attack from demons, causing her to make slanderous accusations against her family, renounce her faith, tear at her own skin, and contemplate suicide. The rest of the Book focuses on her spiritual journey and her conversations with Jesus and God. 106

King Charles VI of France, r. 1380–1422, and King Henry VI of England, r. 1422–61

The lives of mad monarchs stand out prominently in the historical record because of the impact that the madness of a king could have on an entire kingdom. This is a phenomenon that has been investigated by Vivian Green, who also questions whether the label of madness was bestowed on weak rulers to discredit them rather than on those who would otherwise have been recognized as mad. 107 Were the symptoms of madness recognized by contemporaries in their kings the same as those recognized in mad commoners?

R. C. Famiglietti has probed this thesis in relation to King Charles VI of France. He argues that both contemporaries and historians have adopted the viewpoint that Charles’ politically-sound decisions were made during lucid intervals whereas flawed judgements indicate that the King was hindered by madness. 108 Bernard Guenée has explored extensively the contemporary evidence relating to Charles’s ‘madness’, with a consideration of what contemporaries may have thought of their king, in light of the discretion that contemporary writers may have felt compelled to show when describing the scandalous madness of a king. 109

Charles’s grandson, King Henry VI, was King of England from 1422 until he was deposed in 1461. He was briefly restored to the throne in 1470, but the crown was assumed by Edward IV in 1471 and Henry died soon after. Cory James Rushton has argued that Henry’s earlier bout of madness (1453–4) was ‘a key component’ in the collapse of his regime and that of the Lancastrian dynasty. 110 The Duke of York was appointed Lord Protector but later harboured ambitions for the throne: the future Edward IV was his son. Both Rushton and Turner have explored the issue of the wardship of Henry VI, as a mad king. 111 Turner draws attention to the difficulty of circumventing the leadership of a mentally incompetent king whose physical body remained representative of the body politic and thus could not be replaced. 112 A lack of personal self-governance in the figure of the king had huge repercussions for the political and symbolic governance and identity of the state.

Beyond the Christian West: Byzantium and Islam

For a final and unusually vivid example of a mad ruler, we could look back in time to the later sixth century and away from Europe to the eastern Mediterranean. When the late Roman (or Byzantine) emperor Justin II (r. 565–78) lost his reason, he made animal-like noises or rushed about his palace by turns hiding under the bed or trying to throw himself from a window. His attendants had to chase and restrain him, frightening him into submission. But they also tried to restore him to reason by pleasant diversions. They pulled him about (like a child) on a throne mounted on a little wagon and they played music to him on an organ (music therapy akin to that used with Saul – and with Hugo van der Goes). Our source for these amusements is the very hostile chronicler John bishop of Ephesus. 113 He saw in Justin’s madness a divine punishment, achieved through demonic possession – a punishment for the emperor’s persecution of those whom John upheld as orthodox Christians. The doctrinal details of that do not matter here. What is noteworthy, however, is the naturalistic treatment that John ascribed to Justin’s attendants. It was not medical, but it was a form of psychotherapy. John was quite explicitly reporting city gossip rather than eyewitness accounts, yet it is of interest that the gossip was couched in such terms and not, say, attempted exorcism or prayer and penance.

Byzantium is worth including in any survey of medieval madness for two reasons: there is vivid evidence and some excellent scholarship that should be more widely appreciated; and it offers instructive similarities and contrasts with western Europe. Here, despite John’s demonic aetiology of the emperor’s insanity, is a world as capable as any other medieval culture of separating out, at least to some extent, possession from naturally occurring insanity. 114 Byzantium displays a medical tradition that maintained Galenic categories and treatments for mental illness broadly without interruption. There is some evidence of care in monasteries or at shrines for both the chronically possessed and those with such afflictions as an ‘illness coming from the cranium’. But specific hospitals for the insane are not evidenced in the quite detailed prescriptions of founders or the descriptions by contemporaries that survive in plenty from the Byzantine millennium. 115

So far so European. What marks Byzantium more strongly out from the West is the ‘holy fool’. In Byzantium, the mad and the possessed might be killed or restrained, kicked or cast out. Yet, ironically, some of our best anecdotal evidence for the daily life of the insane on the streets of Byzantine cities comes from the biographies written of those who feigned madness. They had become ‘fools for the sake of Christ’: saloi, a special Greek term for this form of piety quite distinct from the vocabulary of insanity. They were following the exhortation of St Paul (I Corinthians 4: 10), to avoid attention from admirers of sanctity and still more as a critique of the corrupt norms of the society around them. Byzantine culture is quite distinct from those of medieval Europe in its high estimation of such forms of sanctity. 116 The few contemporary exceptions that can be mustered (as they have been by Sergey Ivanov) prove the rule that, as we have already seen, this type of feigned insanity was not widely valued in the West. 117

To a brief Byzantine parallel, we should add medieval Islam:

In general, insanity has been presented as a significant aspect of Islamic social history. Insanity as a medical concept was closely related to the development of Islamic sciences and institutions; religious healing [of the insane] was intimately associated with the growth of Muslim saints; and the madman as holy fool was vivid expression of the evolution of Muslim religiosity. Moreover, in the general areas of healing, perceiving, and protecting the insane, there is a remarkable continuity with the pre-Islamic Christian culture of the Middle East. The persistence of the Galenic medical tradition in both theory and practice is obvious. Less evident but equally important is the continuity in religious healing and magic, sacred and profane perceptions of madness, and the legal status of the madman.

Those are the conclusions of Michael Dols’s posthumously published synoptic study of madness in the medieval Islamic Middle East. 118 They have not been bettered, though some might now question the extent to which he mixes medieval evidence with that of nineteenth-century travellers and modern ethnographers to support his vision of continuity. His monumental traversing of documentary evidence, narratives, law, medicine (both Galenic and the Medicine of the Prophet), theology and religious writings, and imaginative literature suggests, as he put it, ‘social tolerance of the mentally afflicted’. Far more than in the Byzantine or western European worlds, moreover, the insane, while never free of the threat of severe restraint and maltreatment, might look for help and healing beyond the family to a variety of healers, saints and mystics, ‘old wives’, magicians, exorcists and doctors. Most strikingly, largely because of that Galenic inheritance, taken over into Arabic from the Greek and Syriac, those who were founding hospitals in the major cities were also patrons of Galenic learning, with its naturalistic and indeed largely somatic conception of mental illness. Their hospitals reflected the fact. From the tenth century onwards, an insane patient might be hospitalized and receive a treatment that relied as much on carefully modulated diet and the psychotherapy of pleasant surroundings, soothing sounds (including musical performances), and beguiling scents as on restraint or beatings.

Conclusions

All conclusions in this fraught area of the history of medieval madness, ripe for further study, must be incomplete or provisional. We have stressed, first, the importance of the background connections posited between mind, body and soul for any understanding of medieval conceptions of insanity; second, the close interplay of the religious and the medical, often more specifically the demonic and the natural, in accounts of causation; and finally the variety of overlapping treatments that might be available, from physical restraint to medication and psychological diversion, not to mention brutality or neglect. These themes run through much of the historiography we have discussed, but the overall picture remains, as we warned at the outset, fragmentary and incomplete. Synthesis of medical, legal, theological and social perspectives on the subject, and the placing of the result of that synthesis in the wider context of beliefs and practices about reason, health and the soul both remain to be accomplished.

Notes

Trans. Faith Wallis, Medieval Medicine: A Reader (Toronto: University of Toronto Press, 2010), 353. For what follows see Peter Murray Jones, ‘Music Therapy in the Later Middle Ages: The Case of Hugo van der Goes’, in Music as Medicine: The History of Music Therapy Since Antiquity, ed. Peregrine Horden (Aldershot and Burlington, VT: Ashgate, 2000), 120–44.

Wallis, 351–2, 356.

Leigh Ann Craig, ‘The History of Madness and Mental Illness in the Middle Ages: Directions and Questions,’ History Compass 12 (2014), 729–44, is a brief but bibliographically rich survey. Among older studies still the most valuable are: George Rosen, Madness in Society (London: Routledge, 1968), H. H. Beek, Waanzin in de Middeleeuwen: Beeld van de Gestoorde en bemoeienis met de Zieke (Nijkerk: Callenbach; Haarlem: de Toorts, 1969), Basil Clarke, Mental Disorder in Earlier Britain (Cardiff: University of Wales Press, 1975), Judith S. Neaman, Suggestion of the Devil: The Origins of Madness (New York: Doubleday Anchor Books, 1975), S. Kemp and K. Williams, Medieval Psychology (New York: Greenwood Press, 1990), Muriel Laharie, La folie au moyen âge XI e -XIII e siècles (Paris: Le Léopard d’Or, 1991), Jean-Marie Fritz, Le discours du fou au moyen âge, XIIe-XIIIe siècles: Etude comparé des discours littéraire, medical, juridique et théologique de la folie (Paris: Presses Universitaires de France, 1992).

E. Ruth Harvey, The Inward Wits: Psychological Theory in the Middle Ages and the Renaissance, Warburg Institute Surveys 6 (London: Warburg Institute, 1975), 33.

For an exploration of medieval representations of Nebuchadnezzar, Penelope B. R. Doob, Nebuchadnezzar’s Children: Conventions of Madness in Middle English Literature (New Haven: Yale University Press, 1974).

Harvey, The Inward Wits, 33.

Ibid., 7–8.

Ibid., 2.

For example, Gerard O’Daly, Augustine’s Philosophy of Mind (London: Duckworth, 1987) and Anthony Kenny, Aquinas on Mind (New York: Routledge, 1993).

Harvey, The Inward Wits, 4–6.

Leslie Lockett, Anglo-Saxon Psychologies in the Vernacular and Latin Traditions (Toronto: University of Toronto Press, 2011).

Ibid., 110–78.

Ibid., 17–53.

Ibid., 427.

Thomas Aquinas, Summa Theologica, trans. Roberto Busa (Rome: Leoninum, 1906), Tertia Pars, Quaestio 68, www.corpusthomisticum.org/sth4066.html (accessed 13 March 2016).

Ibid., Tertia Pars, Quaestio 80, www.corpusthomisticum.org/sth4080.html (accessed 13 March 2016).

Stanley W. Jackson, Melancholia and Depression from Hippocratic to Modern Times (New Haven: Yale University Press, 1986), 74, but see also Andrew T. Crislip, ‘The Sin of Sloth or the Illness of Demons? The Demon of Acedia in Early Christian Monasticism,’ Harvard Theological Review 98.2 (2005): 143–69.

Ibid., 66.

Ibid., 66–71.

Mary Francis Wack, Lovesickness in the Middle Ages: The Viaticum and its Commentaries (Philadelphia: University of Pennsylvania Press, 1990); Amy Hollywood, ‘Acute Melancholia,’ Harvard Theological Review 99.4 (2006): 361–80.

Luke Demaitre, Medieval Medicine: The Art of Healing, from Head to Toe (Santa Barbara: Praeger, 2013).

Jackson, Melancholia and Depression, 113.

Ibid., 127–8.

For Paul of Aegina’s (625–690 CE) theories concerning madness, Jackson, Melancholia and Depression, 54–6. For archaeological and written evidence of Anglo-Saxon medical practice, Christina Lee, ‘Body and Soul: Disease and Impairment,’ in The Material Culture of Daily Living in the Anglo-Saxon World, ed. Maren Clegg Hyer and Gale R. Owen-Crocker (Exeter: University of Exeter Press, 2011), 293–309.

Monica Green, ‘Salerno on the Thames: The Genesis of Anglo-Norman Medical Literature,’ in Language and Culture in Medieval Britain: The French of England, c. 1100–c.1500, ed. Jocelyn Wogan-Browne (Woodbridge: Boydell, 2009), 222.

Hastings Rashdall, The Universities of Europe in the Middle Ages: Salerno, Bologna, Paris, first edn 1895 (Cambridge: Cambridge University Press, 2010), 78.

Avicenna, Canon medicinae (latine): a Gerardo Cremonensi translatus (Venice: Bonetus Locatellus, 1490), 257.

Demaitre, Medieval Medicine, 129.

Ibid., 130.

For an examination of medial theories regarding frenzy, D. Jacquart, ‘Les avatars de la Phrénitis chez Avicenne et Rhazès,’ in Maladie et maladies: histoire et conceptualisation. Mélanges en l’honneur de Mirko Grmek, ed. Danielle Gourevitch (Geneva: Droz, 1992), 181–92.

Constantine the African, ‘Liber Pantegni,’ in Opera Omnia, ed. Isaac Israeli (Lyons: Trot, 1515), I-CXLIV [in the second set of foliation], fo. xljv.

Ibid., fo. xcviijr.

Jacquart, ‘Les avatars de la phrénitis.’

Constantine the African, ‘Liber Pantegni,’ fo. xcicv.

Ibid., and fo. xliv.

Gariopontus, Passionarius Galeni (Lyon: Trot, 1526), fo. vv.

Ibid.

Constantine the African, fo., xcixv.

Ibid., fo. xlijv.

Ibid., fo. xlijr.

Ibid., fo. xcixv.

Jackson, Melancholia and Depression, 63–4.

Fernando Salmón, ‘From Patient to Text? Narratives of Pain and Madness in Medieval Scholasticism,’ in Between Text and Patient: The Medical Enterprise in Medieval and Early Modern Europe, ed. Florence Eliza Glaze and Brian K. Nance (Florence: Sismel, 2011), 390–1.

Constantine the African, ‘Liber Pantegni,’ fo. xcixv.

Rachel Koopmans, Wonderful to Relate: Miracle Stories and Miracle Collecting in High Medieval England (Philadelphia: University of Pennsylvania Press, 2010).

Claire Trenery, ‘Miracles for the Mad: Representations of Insanity in English Miracle Narratives From the Long Twelfth Century’ (PhD diss., Royal Holloway University of London, 2016).

Leigh Ann Craig, ‘The Spirit of Madness: Uncertainty, Diagnosis, and the Restoration of Sanity in the Miracles of Henry VI,’ Journal of Medieval Religious Cultures 30.1 (2013): 61.

Catherine Rider, ‘Demons and Mental Disorder in Late Medieval Medicine,’ in Mental (Dis)Order in Later Medieval Europe, ed. Sari Katajala-Peltomaa and Susanna Niiranen (Leiden: Brill, 2014), 47.

Laharie, La folie au moyen âge, 25–6.

Nancy Caciola, Discerning Spirits: Divine and Demonic Possession in the Middle Ages (Ithaca: Cornell University Press, 2003), 191.

The growing interest in the discernment of spirits is explored in Caciola, Discerning Spirits.

Alain Boureau, Satan the Heretic: The Birth of Demonology in the Medieval West, trans. Teresa Lavender Fagan (Chicago and London: University of Chicago Press, 2006), 122–3.

F. Chave-Mahir, ‘Les cris du démoniaque. Exorciser les possédés dans les récits hagiographiques des XIIe et XIIIe siècles,’ in Haro! Noël! Oyé! Pratiques du cri au Moyen Age, ed. by D. Lett and N. Offenstadt (Paris: Publications de la Sorbonne, 2003), 131.

Sari Katajala-Peltomaa, ‘Demonic Possession as Physical and Mental Disturbance in the Later Medieval Canonisation Processes,’ in Katajala-Peltomaa and Niiranen, Mental (Dis)Order, 109.

D. Barthélemy, ‘La guérison des possédées dans Les Miracles de Saint Benoît,’ in Abbon: Un abbé de l’an Mil (Turnhout: Brepols, 2008), 343.

Boureau, Satan the Heretic, 123.

Ibid., 124.

Robert Bartlett, The Natural and the Supernatural in the Middle Ages (Cambridge: Cambridge University Press, 2008), 109.

Nigel Walker, Crime and Insanity in England, vol. 1 (Edinburgh: Edinburgh University Press, 1968), 15–34.

S. A. Jurasinki, ‘Madness and Responsibility in Anglo-Saxon England,’ in Peace and Protection in the Middle Ages, ed. T. B. Lambert and D. Rollason (Durham: Centre for Medieval and Renaissance Studies, 2009), 99–120.

Alexander Murray, Suicide in the Middle Ages: The Violent Against Themselves (Oxford: Oxford University Press, 1998), 162–5.

Sara M. Butler, ‘Representing the Middle Ages: The Insanity Defence in Medieval England,’ in The Treatment of Disabled Persons in Medieval Europe: Examining Disability in the Historical, Legal, Literary, Medical and Religious Discourses of the Middle Ages, ed. Wendy J. Turner and Tory Vandeventer Pearman (Lewiston: Edwin Mellen, 2010), 117–31.

Ibid., 122–5.

Ibid., 128.

Alexandra Pfau, ‘Protecting or Restraining? Madness as a Disability in Late Medieval France,’ in Disability in the Middle Ages: Reconsiderations and Reverberations, ed. Joshua Eyler (Farnham: Ashgate, 1988), 97.

Wendy J. Turner, ‘Silent Testimony: Emotional Displays and Lapses in Memory as Indicators of Mental Instability in Medieval English Investigations,’ in Madness in Medieval Law and Custom, ed. Wendy J. Turner (Leiden: Brill, 2010), 81–95.

Ibid., 84 and 81.

Wendy J. Turner, Care and Custody of the Mentally Ill, Incompetent, and Disabled in Medieval England (Turnhout: Brepols, 2013).

Kate Parkin, ‘Tales of Idiots, Signifying Something: Evidence of Process in the Inquisitions Post Mortem,’ in The Fifteenth-Century Inquisitions Post Mortem: A Companion, ed. Michael Hicks (Woodbridge: Boydell, 2012), 80.

Ibid., 79.

Ibid., 95.

Colin R. Pickett, Mental Affliction and Church Law: An Historical Synopsis of Roman and Ecclesiastical Law and a Canonical Commentary (Ottawa: University of Ottawa Press, 1952).

Ibid., 11–100.

Ibid., 30.

Ibid., 41.

Ibid., 50.

Ibid., 43–5.

Jerome Kroll and Bernard Bachrach, ‘Sin and Mental Illness in the Middle Ages,’ Psychological Medicine 14 (1984): 507.

Ibid., 509.

Ibid., 511.

Jerome Kroll and Bernard Backrach, ‘Sin and the Etiology of Disease in Pre-Crusade Europe,’ The Journal of the History of Medicine and Allied Sciences 41 (1986): 407.

Sabina Flanagan, ‘Heresy, Madness and Possession in the High Middles Ages,’ in Heresy in Transition: Transforming Ideas of Heresy in Medieval and Early Modern Europe, ed. I. Hunter, J. C. Laursen, and C. J. Nederman (Aldershot: Ashgate, 2005), 31 and 41.

Ibid., 35 and 41.

Ibid., 41.

Katherine Park and John Henderson, ‘“The First Hospital among Christians”: The Ospedale di Santa Maria Nuova in Early Sixteenth-Century Florence,’ Medical History, 35 (1991): 183. For context see further Henderson, The Renaissance Hospital (New Haven and London: Yale University Press, 2006), esp. 312–13.

Jonathan Andrews, Asa Briggs, Roy Porter, Penny Tucker and Keir Waddington, The History of Bethlem (London and New York: Routledge, 1997), 116.

For what follows see Peregrine Horden, ‘The Late Antique Origins of the Lunatic Asylum?’, in Transformations of Late Antiquity: Essays for Peter Brown, ed. P. Rousseau and M. Papoutsakis (Farnham and Burlington, VT: Ashgate, 2009), 259–78, esp. 276–7.

Horden, ‘Origins,’ 260–61.

Harper discusses various approaches to ‘madness’ and ‘folly’ and the boundaries of terminology in French and English scholarship. Stephen Harper, Insanity, Individuals, and Society in Late-Medieval English Literature: The Subject of Madness, Studies in Medieval Literature 26 (Lewiston: Edwin Mellen, 2003), 11–4.

Ibid., 19.

Doob, Nebuchadnezzar’s Children, 54–5.

Harper, Insanity, Individuals, and Society, 20–1.

Sylvia Huot, Madness in Medieval French Literature: Identities Found and Lost (Oxford: Oxford University Press, 2003), 1 and 9.

Ibid., 2.

Ibid., 136–209.

Ibid., 180.

Corinne Saunders, ‘“The thoughtful maladie”: Madness and Vision in Medieval Writing,’ in Madness and Creativity in Literature and Culture, ed. Corinne Saunders and Jane Macnaughton (Houndmills: Palgrave Macmillan, 2005), 74.

Renée L. Curtis, ‘Tristan forsené: the Episode of the Hero’s Madness in the Prose Tristan,’ in The Changing Face of Arthurian Romance: Essays on Arthurian Romance in Memory of Cedric E. Pickford, ed. Alison Adams, Armel H. Diverres, Karen Stern and Kenneth Varty (Woodbridge: Boyell, 1986), 10–22.

Ibid., 11.

Doob, Nebuchadnezzar’s Children, 76.

Caciola, Discerning Spirits, 36–40.

Sander L. Gilman, Seeing the Insane (Lincoln: University of Nebraska Press, 1996), 2–21.

Ibid., 44–7.

Richard Lawes, ‘The Madness of Margery Kempe,’ in Medieval Mystical Tradition: England, Ireland and Wales, ed. E. A. Jones (Cambridge: D.S. Brewer, 1999), 147.

Alison Torn, ‘“Margery Kempe: Madwoman or Mystic – A Narrative Approach to the Representation of Madness and Mysticism in Medieval England,’ in Narrative and Fiction: An Interdisciplinary Approach, ed. David Robinson, Pamela Fisher, Noel Gilzean, Tracey Lee, Sarah Jane Robinson, and Pete Woodcock (Huddersfield: University of Huddersfield, 2008), 79–80.

For a modern English translation, Anthony Bale, trans. The Book of Margery Kempe (Oxford: Oxford University Press, 2015). For the section on madness, 11–13.

Vivian Green, The Madness of Kings: Personal Trauma and the Fate of Nations (Stroud: Sutton, 1993), xiii.

R. C. Famiglietti, Royal Intrigue: Crisis at the Court of Charles VI, 1392–1420 (New York: AMS Press, 1986), 1.

Bernard Guenée, La folie de Charles VI: roi bien aimé (Paris: Perrin, 2004), 23–34.

Cory James Rushton, ‘The King’s Stupor: Dealing with Royal Paralysis in Late Medieval England,’ in Madness in Medieval Law and Custom, ed. Turner, 150.

Wendy J. Turner, ‘A Cure for the King Means the Health of the Country: The Mental and Physical Health of Henry VI,’ in Madness in Medieval Law and Custom, ed. Turner, 177–95.

Ibid., 177–8.

John of Ephesus, Ecclesiastical History, pt 3, bk 3, chs 2–3, ed. E. W. Brooks (Paris and Louvain: Corpus Scriptorum Christianorum Orientalium, 1935), vol. 105, 149–53 (Syriac); trans. R. Payne Smith (Oxford: Oxford University Press, 1860), 166–70. For full details of the text and editions see http://syri.ac/johnofephesus#EH (accessed 13 March 2016).

Margaret Trenchard-Smith, ‘Insanity, Exculpation and Disempowerment in Byzantine Law,’ in Madness in Medieval Law and Custom, ed. Turner, 39–55, at 44.

The main monographs, neither wholly reliable in their interpretations: Timothy S. Miller, The Birth of the Hospital in the Byzantine Empire, 2nd edn (Baltimore and London: Johns Hopkins University Press, 1997); Demetrios J. Constantelos, Byzantine Philanthropy and Social Welfare, 2nd edn (New Rochelle, NY: Caratzas, 1991).

Horden, ‘Responses to Possession and Insanity in the Earlier Byzantine World’, Social History of Medicine, 6 (1993): 177–194.

Sergey A. Ivanov, Holy Fools in Byzantium and Beyond (Oxford: Oxford University Press, 2006).

Michael W. Dols, Majnūn: The Madman in Medieval Islamic Society (Oxford: Clarendon Press, 1992), 475.

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