Preliminary Issues 305explanations of mental illness and cruel mistreatment of the
mentally ill can be traced primarily to textbooks of psychia-
try that promulgated the value of Freudian ideas. The claim
that during the fifteenth century the mentally ill were placed
on “ships of fools” and sent out to sea derives from Michel
Foucault’s, Madness and Civilization: A History of Insanity
in the Age of Reason(1961/1965). Foucault presented his
speculations about the historical treatment of the mentally ill
to illustrate his conjecture that, in order to define themselves,
the dominant group in a culture must exclude others who do
not share the aspects they consider most important, reason, in
the case of the mentally ill. The fictitious nature of Foucault’s
ship of fools has been thoroughly demonstrated (Maher &
Maher, 1982).
No documentary evidence records prehistoric belief sys-
tems; nevertheless, the lack of evidence has not deterred writ-
ers of the history of psychopathology from making assertions
about the beliefs held by prehistoric peoples regarding the
cause and treatment of mental illness. Many such histories
open with the statement that prehistoric man believed that
deviant behavior was caused by demon-possession and so cut
a hole in the skull of a mentally ill person in order to let the
demon escape. A photograph of a prehistoric skull with a
roughly circular hole in it is presented as evidence for this
allegation. This popular myth of the trephined (or trepanned)
skull has in it all of the elements of guesswork plus ignorance
and indifference to actual evidence that characterize such
myths.
Archaeologists have unearthed a large number of such
skulls and dated them to the Neolithic period. The holes in
the skulls are usually symmetrical and are thought to have
been intentionally incised by the surgical technique of trepan-
ning. Thickening of the bone around the margins of the holes
in many of these skulls suggests healing and that the patient
survived the operation for some time. We do not know the
mental state of the patient and no direct evidence explains
why the hole was cut. (See MacCurdy (1924) for more on
trephining.)
Although we cannot prove wrong the assertion made
about the trepanned skulls, neither can we prove it correct.
It is based on ana prioriassumption about prehistoric man
first advanced by the French neurologist, Paul Broca
(1824–1880), when Neolithic trepanned skulls were found
in the 1870s. Broca “felt that primitive man had made
these holes in skulls in order to liberate evil spirits who
might be causing headaches or epilepsy” (Ackerknecht,
1982, pp. 8–9). It is likely that Broca was influenced by a
widely accepted theory of stages advanced by Auguste
Comte (1798–1857), the French philosopher/sociologist
who founded the school of positivism. Comte (1830–1842),
proposed an inevitable progression in mental development of
peoples through three major stages. The first stage is the
superstitious theological stage, which progresses through
(1) animism (the belief that each object has its own will),
(2) polytheism (the belief that demons, spirits, and deities im-
pose themselves on objects), and (3) monotheism (the belief
that one God imposes his will on all things).
In the second metaphysical stage it is believed that natural
events are caused by occult physical forces. In the third sci-
entific stage, positive knowledge of natural causes replaces
superstition and metaphysics, and humans turn to the study of
laws “of relations of succession and resemblances” in order
to understand events in the natural world. It followed that
primitive humans at the animistic stage of reasoning about
the world would not react in the same way as civilized
humans. Subsequently, interpretations of Darwin’s theory of
evolution by natural selection published in 1859 reinforced
the assumption that prehistoric peoples would have been too
intellectually primitive to perform trepanation as a rational
surgical technique.Early Attempts at ClassificationFor many centuries, the dominant view held that mental ill-
ness, although differing in symptoms and severity, is funda-
mentally one general disorder called melancholy. However,
in the seventeenth century, a view began to develop that
mental illness is an umbrella term encompassing a number of
distinguishable mental diseases. Robert Burton (1651/1927)
wrote, “Some confound melancholy and madness, others say
melancholy is madness differentiated not in kind but in extent
or degree, some acknowledge a multitude of kinds and leave
them indefinite.” This view became popular after the discov-
ery that mental illness as well as physical diseases differ not
only by symptoms but also by cause.
In the nineteenth century, attempts were undertaken to
identify and classify types of mental illness on the basis of
clusters of symptoms, etiology, course, and response to treat-
ment. The view that psychopathology is a general pathology
again emerged in the middle of the twentieth century when
learning theorists proposed that psychopathology represents
maladaptive responses to stress, and psychoses differ from
neuroses on a dimension of severity, unless the pathology had
been clearly determined to be caused by a demonstrable
lesion of the nervous system.
Today it is again generally held that diagnostically distinct
psychopathological disorders exist that differ in symptoms, eti-
ology, course, and response to different kinds of treatment. In
1952, the American Psychiatric Association published the first
edition ofThe Diagnostic and Statistical Manual of Mental