Journal of the History of the Behavioral Sciences, Vol.

41(2), 165183 Spring 2005 Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002 /jhbs.20081 2005 Wiley Periodicals, Inc.

BLOCKHEADS, ROUNDHEADS, POINTY HEADS: INTELLECTUAL DISABILITY AND THE BRAIN BEFORE MODERN MEDICINE
C. F. GOODEY

Recent work on the conceptual history of intellectual disability has pointed to a discontinuity in the seventeenth century, identifying the concept as essentially modern in a more radical sense than mental illness or physical disability. However, Galenist accounts of intellectual impairment were clearly connected (via anatomy) to neurology, which could be taken as prima facie evidence that Galenism shares with modern medicine one of its basic explanatory approaches to intellectual disability. Close textual examination does not bear out this counter-claim, at least as far as the conceptual apparatus itself is concerned. However, it does reveal a degree of continuity in the medical mind-set as discourses of monstrosity were transposed from the domain of anatomy to that of post-Cartesian psychology. 2005 Wiley Periodicals, Inc.

How did premodern doctors conceive the links between psychology on the one hand and neurology and anatomy on the other? Various writers have investigated the treatment by classical and Renaissance medical writers of this topic (Manzoni, 2001; Rocca, 1997; Wiberg, 1914/1996), but there has been little discussion of one particular theme on which they held clear views: that is, the relationship of intellectual or cognitive performance to head size, head shape, and the layout of the cranial sutures. I shall try to fill this gap. However, I want also to place it in the broader context of the emergence of modern concepts of intellectual disability (formerly mental retardation or mental handicap). Recent writing has raised questions of continuity and rupture in its longterm conceptual history. Three historiographical approaches can be discerned, though there is only room here to state them crudely (for the start of a deeper theoretical investigation, see Stainton & McDonagh, 2001): 1. A biological-cum-psychological concept of intellectual disability has always existed, describing roughly the same group of people; the concept thus crosses historical boundaries. This is the commonsense starting point always assumed, rarely theorized, in the little conceptual history that has been done on the topic (see, for example, Scheerenberger, 1983). The positive biological and psychological phenomenon of intellectual disability has always existed, but its conceptual history only starts with its scientific discovery and description in modern times. This has the same positive starting point as position 1 but rules out the primitives who lacked modern medical and psychological expertise (for example, Kanner, 1967). Intellectual disability is only a modern phenomenon. There may be transhistorical biological characteristics but not psychological ones, and the intellectually disabled people we recognize are not necessarily the same people as the fools our

2.

3.

C. F. GOODEY studied at the University of Cambridge and is currently a research associate at the Social Science Research Unit, University of London Institute of Education, and an associate lecturer in the social science faculty of the Open University. He has published extensively on the pre- and early modern history of psychological concepts, especially those concerning human intelligence and intellectual disability. He is also an advisor on inclusive education to U.K. governmental organizations and is a founding member of Human Genetics Alert, the United Kingdoms voluntary watchdog body on the new biotechnology.

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forebears recognized. Here the notion of rupture appears in a strongly constructivist form, such that once upon a time there were no mentally retarded people (Mans, 1998). The particular form of position 3, which I myself have argued (Goodey, 2004), amounts to the following. Galen and his Renaissance interpreters could not have described anything we might recognize as intellectual disability. First, its conceptual origins belong in law, political theory, and, above all, theology, not in medicine. If intellectual disability existed before modern medicine, it was not as a medical concept. And second, it is essentially modern; not only was it the offspring of disciplines other than medicine, it emerged from them and eventually became an object of doctors anxiety only as Galenism was dying. The intellectually disabled person and the natural fool of earlier times were each created by quite separate sociohistorical contexts and, more importantly for present purposes, were described by quite different characteristics. Break intellectual disability down into its discursive components and they are all attached to some essentially modern theoretical principle. Intellectual disability assumes that the disabled mind can be known separately from the disabled body (Cartesian dualism); that the intellectually disabled are a statistical abnormality (psychiatric pathology); that a specific intellectual ability defines the human species, thus rendering their membership dubious (natural history); that intellectual disability is biologically caused (nature as determinism); and that it confers on the individual a permanent identity lasting from birth to death (phenomenal-type discourses of personhood). What does all this say about our knowledge of actual people? Put some people with learning difficulties in a time machine, send them to Rome or even early medieval England, and ask a doctor of that time if they correspond to people he would call fools, and the answer will rarely be yes, though similar time experiments would yield positive results with physically disabled people and with a significant number of the mentally ill. Associating psychology with neurology and anatomy, however, poses a challenge to this constructivist position. Some Galenist texts explicitly deal with the links between intellectual impairment of some kind and the head, skull, or brain. The very idea that such a relationship is possible implies some long-term historical continuity. It suggests both a conceptual distinction between intellectual processes and their bodily organ, and some degree of causality in that relationship, and the brain is the one organ that, more than any other, might be thought permanently to fix our personal identity. This suggests that Galen or a European Galenist of the Renaissance could have recognized in the people thus identified the characteristics we recognize in our own intellectually disabled people, or at least a significant overlap. My account of Galen and Galenism on the relationship between psychology and anatomy does indeed lead me eventually to conclude that the idea of conceptual rupture as simply stated in position 3 is not justifiable, but alsoas we shall seethat the particular challenge to it set out above is not justifiable either. GALEN AND THE SOURCES I shall be dealing mainly with medical texts, rather than physiognomics as a whole. Elements of classical physiognomics, the theory and practice of reading a persons character from bodily signs and especially the head, found their way into the medical textbooks of the Romans, including Galens. Medieval writers increasing acquaintance with Galen stimulated a new interest in the classical sources of his physiognomics. So early modern Europe had two textual traditions: one medical and Galenist with embedded physiognomic elements, the other purely physiognomic.

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Like psychology today, physiognomics provided a theoretical link from the realm of nature to that of morals and behavior, and a practical guide for policing them. Greek and Roman social elites used it to recruit new colleagues to schools of thought and public office, to prove the stupidity or degeneracy of opponents, and to select wives, servants, and wet nurses (Agrimi, 2002; Frischer, 1982). In the thirteenth century, physiognomics was on the curriculum of the first universities at Bologna and Paris, and as a diagnostic tool, it contributed to their role in training intellectuals to administer the rapid expansion of papal and state power. In the sixteenth century, it was an archetype of useful humanist knowledge, a practical ethical skill for civic leaders that also provided social integration and advancement for the intellectuals who taught it. Countless physiognomic manuals, often printed in tabular form (the equivalent of a modern managers bullet points), supplied short-cuts to certainty about people in public life (Tsounas, 1998). This pure physiognomics drew inferences from head size and shape to human character, morals, and behavior, though unlike its medical variant, it did not discuss events inside the brain, nor did it describe causes in the modern biological sense. A certain head shape might be an external sign of stupidity, a condition that could largely be reduced to laziness and physical inertia (the word was equally used of muscles and limbs) and was associated with unfitness for the individuals social calling. The medical texts examined below were somewhat different. In addition to external signs, they discussed certain material operations and conditions internal to the brain, particularly the balance of the four elements and their qualities (hot, cold, wet, dry). In Galen, the material form taken by a specific imbalance of these elements amounted as such to a specific impairment. The classic text in this respect was the systematic discussion that takes up book 3 of On Affected Places (1965a). It was much used by later authors, either directly or in the form transmitted by Ibn Sina. Here Galen listed the impairments very precisely. They were: coma, apoplexy, paralysis, catalepsy, vertigo, lethargy, carus (lethargy in its extreme form), melancholy, epilepsy, and phrenitis. He neither gave these any general overarching heading nor made a clear distinction between intellectual and physical. As well as the four elements, and especially in medieval and Renaissance Galenism, there were other kinds of internal material: the brains substance, the spaces or ventricles that substance encloses, and the intangibly fine yet material animal spirits (soul spirits). These material constituents of the brain and the activities of the intellect (dianoia) itself, plus the size and shape of the head, were all to be taken together as signs, not of the patients moral character as such, but of cerebral health, which had, nonetheless, a moral inflection. Health was a question of balance. Now the idea of balance would seem to be based on fluctuation and thus transience, rather than permanence. A defective mixture of elements and humors could be temporary, as it was in fevers, or it could be something much longer-term. But tenacious as the mixture may have been, even if it lasted from birth to death, it amounted simply to a disposition. And inasmuch as it suggested differences among individuals, the difference was in degree rather than in kind, and did not raise problems about their membership of the species rational animal, to use the archetypal scholastic description of man. Nor did explanations of long-term states differ essentially from explanations of that which was temporary. Structure and size of the head, and thus of the brain, were as important as internal balance. But while it seems common sense that imbalance might be transient, the idea that the anatomical structure of the head belongs to a realm of transience seems curious, at least to us. There could hardly be anything less transient, more permanent about our bodies than the shape and size of our heads. The idea might have seemed less curious to contemporaries, for two reasons. First of all, there were metaphysical constraints on applying the notion of permanence to human character. For Aristotle, the fact that a given human characteristic is permanent, even

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if it belongs to each and every member of the species, is not enough to qualify it as an essential property of that species. That is because the very notion of permanence suggests a need to keep checking that the characteristic is still there (1960, p. 482). In Aristotelian terms, the essential property of what it is to be human must a priori lack incompatible elements, and is therefore already proof against any need for checking. Likewise, for Christian philosophers, our divinely created intellective soul, which was perfect and free from organic or material influences, could not be described as permanent, since this would imply that it belongs in the temporal sphere, subject to natural rather than divine determination. This had some influence on contemporary descriptions of the less perfect, earthbound organic soul, which informed the body and the senses. In short, permanence did not necessarily indicate identity in the way it tends to for us.1 Second, physiognomics and the theory of elements and humors did not just exist alongside each other; they jointly inhabited the same explanatory realm. According to the widely known pseudo-Aristotelian textbook on the subject, body and soul interact, and so the body is subject to sympathetic change: When there is a change in the disposition (hexis) of the soul, it simultaneously changes the shape (morphe) of the body; conversely when there is a change in the shape of the body, it changes the disposition of the soul (Aristotle, 1936, p. 104). Admittedly, the illustration of this point went no further than grieving people with gloomy faces and happy people with cheerful ones. However, the author was not making the trivial point that grief and happiness cause certain facial expressions. Rather, he was demonstrating the synchronicity of the two as proof of the sympathetic interaction between psychic and bodily states. In Renaissance texts, mental or behavioral phenomena and bodily ones such as head shape belong on the same side of the signifier/signified divide: they signify, alike, an underlying constitutional (im)balance. Physiognomists did not necessarily take the sign to be something physical and the signified something mental, or vice versa (Tsounas, 1998). Galen discussed head shape in four works (1965b, 1965c, 1965d, 1965e). The suitable (oikeios) head shape for a healthy brain is an elongated sphere, slightly depressed at the sides (1965d, p. 751). Unsuitable shapes were due to an absence of cranial sutures. A Hippocratic author had originally described four different arrangements of the cranial sutures, without saying whether one was more suitable than another (Hippocrates, 1979a, p. 182). The only Hippocratic author to attach a value to a particular arrangement claimed, in another text, that four sutures were healthier than three, though he did not say why (1979b, p. 284), while Aristotle later claimed that humans have more sutures than other animals, on his usual assumption concerning biological structure that more means better (1937, pp. 70, 154). None of these texts discusses intellect or character. The first of the two Hippocratic authors visualized each of the sutural arrangements as a letter of the Greek alphabet. Galen, followed by dozens of Renaissance commentators, copied this descriptive device. The healthy brain sits in a skull where one suture (the coronal) runs across the front of the skull from one side to the other, down to just in front of the ears; another suture (the lambdoid) runs parallel to it across the back; and a third (the sagittal) runs down the middle from front to back, joining the other two at their respective midpoints. Viewed from above and from the side, the arrangement of sutures thus resembles an H. There are unsuitable skulls, however, where the coronal suture is missing and likewise the frontal projection. Viewed from above and from the front, the resulting arrangement is a T. In others, the lambdoid suture and, thus, the rear projection are
1. Legal suppositions of permanent incompetence on the whole came before medical ones. Effectively, however, these too were latecomers, not being acted upon by the judiciary until the end of the sixteenth century (see Neugebauer, 1996). And the exact characteristics of the legally designated idiot were scarcely modern; most likely they were the ad hoc invention of predatory guardians.

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missing; viewed from above and from behind, the arrangement is a T again. In yet other unsuitable skulls, both the frontal and rear projections are missing. In this case, the sagittal suture is still in place, but it is intersected by a single transverse suture running across the middle of the skull. Viewed diagonally, this arrangement is an X. Galens description of sutural layout appears in On Bones (1965c) and On the Use of Parts of the Body (1965d), of which the second is the more extensive. Here he described the unsuitable shape where one or another eminence was missing as a pointy head. He said nothing about impairment of the intellect (dianoia), which in any case was for Galen not the unitary possession of an individual human type (a thoroughly modern concept that it would be anachronistic to read back into the original), but a continuous series of intellectual states. However, in addition to the suitable shape (the elongated sphere) and the three types of excessively pointy heads: It is possible for a fourth type of pointy head to be imagined, albeit not to exist, which measures longer from ear to ear than from front to back. If this type were to exist, it would not accord with nature and would be the opposite of spherical: its length would become its depth. Now so great a deviation from the natural could not exist; it would be a monstrosity rather than just a pointy head, and would not be capable of life. . . . Either the front or the rear eminence might be absent, or indeed both at the same time, but not to such an extent that some of the brain itself is missing. (Galen, 1965d, p. 754) Galen went on to complain that the Hippocratic author did not mention this other head shape, although as the type is only hypothetical, it is unclear why his predecessor should have done so. According to Galen, missing some of the brain would make the creature unviable, just as missing some of the heart or liver would. The monstrosity here is anatomical: Galen made no mention of the intellect or its impairment at precisely this point. He did, however, cite here the pointy head and lame, bandy legs of Thersites, a character from Homers Iliad who in Book 2 steps out from the ranks to attack the Greek leaders warmongering. Homer was linking physical deformity with oppositional, defeatist politics in the way a pro-war cartoonist might do today. This may have implied a link between body and psyche, though Homer presented the psychic deformity only in external, behavioral terms, which involved playing the fool and was clearly Thersitess own moral responsibility. Although the sutural layout is not mentioned in the other two texts, it is implied in the appearance here too of pointy heads. The first of these texts, The Art of Medicine, I shall discuss in due course. The second, the Commentary on the Epidemics 6 of Hippocrates, was a relatively obscure text. Here Galen did indeed make a connection between intellectual functions and head size: It seems that matters to do with the intellect are clearly harmed in those whose head is too large or too small (Galen, 1965e, p. 818). The intellect (in its Galenist sense) of a large head is usually faulty, though the Athenian political leader Pericles, whose head was notoriously big, was an extremely alert thinker (sunetotatos). The intellectual defect of a small head, however, is invariable. One should try to avoid reading this through the lens of mind-body dualism. In a small head, states of intellect are merely one sign among others, including, for example, small eyes, stuttering and proneness to anger, of the main object of concern: namely, the overall health of the cerebral organ and its proportionality to the other organs, to the neck and chest, and ultimately to the whole body. A large head indicates a long and, therefore, weak neck. The teeth of the upper and lower jaws do not fit: Such people constantly have headaches and ears that weep with a thin and watery or purulent and stinking matter producing much evil superfluity (Galen, 1965e, p. 822). This relates to the sutures, whose function is precisely to evacuate fluids from the brain.

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Galen only discussed intellect in relation to shape and size in the one passage quoted above about matters to do with the intellect being harmed. The difference between excessively large and small heads, he continued, is that in a large head the brain and medulla being bigger, there is a large flow of spirit (pneuma) and room for it; the opposite is the case with small brains. Here as elsewhere Galen was reticent about the neurological aspects of intellect and intellection: he said merely in the most general terms that they are dependent on the quality and mixture of the spirit (Rocca, 1997). One might almost say he was uninterested. Indeed, why might he have been interested in the first place? He was concerned with the health of each principle or main bodily organ; the state of the intellect was important only as a secondary indicator of the health of this particular organ, the brain. GALENIST ELABORATIONS This section requires some initial caveats. First of all, most late medieval and Renaissance references to head shape outside of anatomical compendia are to be found in the many commentaries on The Art of Medicine, the reason being that this text had held a central place on the medical educational curriculum from the twelfth century onward. In fact, of the four texts of Galens that discuss head shape, it has the least to say on the subject. Commentaries on The Art of Medicine nevertheless cross-reference to the other three texts. Second, these commentaries often contain more extensive discussions of the connection between physiognomy and intellectual abilities or impairments than any of Galens originals. It is not possible to be comprehensive. Third, I have not pursued the theme into the wider medical literature beyond the commentaries. And finally, because I want to focus on the theme of continuity or rupture between Galenism and modern medicine on intellectual impairment, I deal with the Galenist commentaries en bloc. In fact, they arrived in distinct waves and in distinct historical settings (see Joutsivuo, 1999, pp. 3338). Nevertheless, while there were many issues that they disputed, on our particular topic, they largely shared their understanding (if not the fine detail of their interpretation) of the sources. The commentators sharper focus on impairment came from their interest in what happens inside the brain. In addition to elements and humors, they speculated about brain substance, the cerebral ventricles and the operation of the animal spirits. What contemporaries called the internal senses, roughly corresponding to what we would call cognitive activity, were organic to these material entities. The substance of the brain was a container for the ventricles, perceived as spaces that cognitive activity inhabits (Manzoni, 2001, p. 37). With elaborated descriptions of the animal spirits came an elaborated description of the internal senses. And the sensitive, organic soul was now conceptualized somewhat separately; it was a stable psychological object in Danzigers (1997) sense. Consequently, there was a greater sense of its precise location in the brain. While Galen had made vague asides about the soul residing in the brain substance, the commentators organic soul had specific operational roles in specific cerebral ventricles. With this greater interest in the internal conditions of the brain and its operations came more elaborate accounts of the relationship between size and shape. The optimum head size was usually a mean. Some writers claimed that Aristotle attributed excellence to small heads, though in fact this was merely an inference from what he had to say about the intellectual connotations of dwarfism, where the head seems large in proportion to the body (1937, p. 369). For Galen, as we have seen, a small head was invariably defective. Galen himself had referred to spirit in this context only in passing, but later Galenists speculated more about the relationship between size and the (internal) characteristics of the animal or soul spirits and the

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cerebral substance through which they move. Their sources were mainly Arab. According to Ibn Ridwan in the tenth century, the reason why smallness, as Galen testifies, is the essential sign of a bad brain composition is because in a small brain there is a constriction of the channels and ventricles . . . since the animal spirits cannot have the due space in the brain that would let them move freely to their completed operations (1523a, p. 94); the formula was repeated by Ibn Sina (1522, p. 134). This constriction led, according to the sixteenth-century commentator Giovanni Argenterio, to the spirits being compacted, burning up because they become excessively dry. Correspondingly, the large head tends to be excessively humid (1566, p. 215). All these material phenomena were linked to the five senses and to muscular activity: Argenterios contemporary Oddo degli Oddi remarked that a small head leads to a smallness in the nerves relating to the [external] senses; all the senses are weak and the operations of motion are weak (1574, p. 118). If a large brain, by contrast, is not necessarily faulty, that is because such insoluble problems of constriction do not arise. According to Galeazzo di Santa Sofia, writing at the start of the fifteenth century, the large brain has the merit of a good composition, with open channels in which clear spirits pass freely from one to another without much confusion of images; however, it is far from well-tempered because there is an abundance of material relative to . . . the virtue, [which] cannot cope with the great amount of material (1533, p. 102).2 In Jean Riolans commentary of 1578, a large head might indicate an incapacity (impotentia) of nature, which cannot produce material (1631, p. 41). A large brain has so much room that the animal spirits can get lost. However, this is not necessarily the case, whereas in a small brain the limit on the amount and mobility of the spirits is definitive. The emphasis on internal conditions created space for debate about the causal relationship between these conditions (brain substance and/or animal spirits) on the one hand and what Argenterio called things further back, structure rather than temperament, on the other (1566, p. 219). The very existence of such a debate seemed to sharpen the focus on the cognitive performances of the internal senses. Even if it is of fundamental importance for size and shape to be proportionate (according to Martin Akakia, the head must have symmetry with the rest of the body), this external structure may not be decisive. Akakia, professor of medicine at Paris in the mid-sixteenth century, said that brain substance [in a small head] is necessarily little, the ventricles narrow and the animal spirits few and insufficient for their functions. . . . [but] while they are imperfect, they are not necessarily faulty, as long as the soul can properly apprehend and render intelligible the images of things and pay attention (1544, p. 101). However, it may not be able to pay attention for long, nor conceive of something difficult, since where cogitations are long and drawn out, more spirits are expended than the faculty of the brain ventricles can supply and, thus, the faculty becomes tired sooner. When the theory of ventricular localization entered medieval European medicine, it had the similar effect of enhancing the internal senses as a conceptually separable realm of investigation. This theory linked specific cognitive functions with specific cerebral ventricles. Variations in the size of the latter were observable externally, by head shape. In the simplest form in which the theory appears, imaginatio belongs in the front ventricle, cogitatio in the middle one, and memoria in the rear. As Rocca (1997) notes, Galen had placed spirit and intellect (dianoia) in the ventricular system in general. All three cognitive functions are mentioned in his works, but he was vague about allocating particular functions to particular ventricles. His main observation was that the ventricles as a whole store and distribute psychic
2. As understood by most Renaissance authors (though not by its original source, Ibn Sina), virtue is tantamount to faculty, the power or force by which the internal senses operate.

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pneuma through the nervous system. Given the centrality of the soul in medieval and early modern theory, it is no surprise to find the sharply outlined version, and its threefold association of the ventricles with imagination, cognition, and memory, coming from one of the early Christian fathers, Nemesius, who was also a doctor and a Galenist (Moreni, 1987, p. 68). A more elaborated schema came from Ibn Ridwan, though he did not use it to relate head shape to cognitive processes within the brain; this relationship, and its prominence in early modern psychological theory, was due rather to the later, more complex version of Ibn Sina. This period, then, gave rise to an expanded account of cognitive performance and impairment and of its material and organic aspects. What, more precisely, were the characteristics of such impairment? The question must be considered in the light of certain fundamental disputes of the time, some of which we have already come across. First, there was the classical discourse of proportionality. This led to arguments over priority between size and shape. Giovanni Sermoneta, an early fifteenth-century commentator, described how some of his colleagues regarded size as most important because the head had to be proportionate to the size of the rest of the bodily organs, while others had thought it a secondary issue on the grounds that it is better for the head to be perfectly shaped but small sized than proportionately sized but imperfectly shaped. For example, although imagination is housed in the front ventricle, a correspondingly large frontal eminence would not necessarily indicate a greater power of imagination; in fact, the opposite might be true (Sermoneta, 1498, p. 53). Second, there were disputes about precedence between structure and internal conditions such as balance, mixture, and so on. Santorio Santorio, writing in 1611, explained how some earlier commentators had claimed that the cause of wisdom (prudentia) in man is a variety in the structure of the brain, while others had replied that balance is prior: the bad structure, and the pointy head . . . have their origin in bad mixture, and narrowness of the brain is merely a trigger or proximate cause of impairment (1632, p. 214). Thirds, an important issue for ventricular theory was whether an injury to part of the brain affects the rest of it, or whether it remains localized in one of the ventricles with the damage being restricted to that part. This exact question could also be asked of the three internal senses, housed in the ventricles. There was a further problem. If injury did affect the whole cognitive process, then would this also harm the intellective soul, and could it do so without making it seem as if the creator was responsible for harm? This theological issue involved the sutures too, since the lack of an eminence, caused by the lack of a suture, might create impairments similar to an injury to that part. Ugo Benzi, writing at the beginning of the fifteenth century, claimed that an absence of one or another eminence, or of a section of it, did not necessarily indicate weakness of brain matter (1498, p. 21). Others, as we shall see, assumed a positive answer. What were the precise characteristics that cognitive impairment displayed? Certainly nothing like an absence of abstract thinking. A regular pattern runs from Pietro dAbano in the late thirteenth century, through the various commentaries on Galens Ars Medica, to Santorio in the early seventeenth century. Small-headed people were by disposition fearful and stupid, inattentive (stolidi, temerarii) (Jeremie de Dryvere, 1547, p. 108); they were unstable, by turns stolidos and ecstaticos (dAbano, 1565, p. 119); or they were inconstant and fearful (Benzi, in Giovanni Manardi, 1541, p. 195). Big heads, being too humid, are stupid (stulti ac fatui) and have the leaden wit (ingenium) of the lazy and somnolent man (Riolan, 1631, p. 41); the bigger the brain the colder it is, thus actions are dulled . . . and we look upon big heads as dull (hebetes), mindless (amentes) and full of catarrh (dAbano, 1565, p. 119).

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The actions referred to are those of the nervous system as a whole: unlike the modern model of intellectual disability, they are a seamless blend of physical, cognitive, and moral. Dryvere, Benzi, and the first quotation of dAbano employ the classic descriptive terms for melancholy, the paradigmatic impairment of the internal senses. Riolans stupidity and leaden wit were secondary symptoms of a character type defined above all by laziness and somnolence; elsewhere in the same commentary, he used the word stupid also to describe the purely physical motion of the animal spirits (1631, p. 56). Of the terms in the second quotation from dAbano, hebes usually described defects of the five external senses and, only by extension (moreover, rarely before the seventeenth century), the three internal ones; amentia was mainly symptomatic of certain stages in acute physical disease. These same terms could also describe temporary states of mental illness and, once again, melancholy. The moral aspect of stupidity (stoliditas, stultitia, fatuitas) appears in the laziness and in the ridiculous behaviour of Thersites (Riolan, 1631, p. 41). The category distinction between this and the social or occupational role of the jester is weak. It is true that we find phrases such as with sound intelligence (ingenium) and sound moral habits (mores) used by Giovanni da Monte (1554, p. 132), professor of medicine at Padua in the mid-sixteenth century, but as the general context here and elsewhere shows, this did not necessarily imply a category distinction. The commentators dealt with shape in a similar way. For example, Sermoneta described how when the forehead is bigger [than the rest], it indicates a ponderousness extending to stupidity (stultitia), and when it is broad it indicates a paucity of discretion (1498, p. 53). He illustrated this with the pointy head of Thersites the fool: the norm was practical wisdom (prudentia), its opposite the stupidity (stultitia, fatuitas, stoliditas) indicated by Thersitess pointy head. Or imperfect shape might indicate a nonlocalized impairment in all the principal actions of reason such as imaginatio, cogitatio and memoria (Oddi, 1574, p. 118). But once again we need to ask: What was the actual content of this stupidity? Writers throughout the period, when commenting on shape, tended to illustrate it with conditions such as apoplexy (du Laurens, 1628, p. 8; Santorio, 1632, pp. 191, 214) or epilepsy (Oddi, 1574, p. 119). Argenterio, in claiming that those who are fatuous, stolid, mindless or otherwise badly turned out have a deficient head structure (1566, p. 218), took his examples for this from Galens standard list mentioned above (1965a): coma, apoplexy, paralysis, catalepsy, vertigo, lethargy, carus, melancholy, epilepsy, and phrenitis. Fatuity, stupidity, and mindlessness, he said, were symptomata and effects of [these] diseases. Furthermore, the symptoms were treatable. And if balance and mixture could interact with morphology, then therapy might be appropriate, even for things as seemingly determinate as skulls. The Hippocratic author of Airs, Waters, Places described a country inhabited by macrocephali who used cranial molding on their children from birth (1923, p. 110) because of custom, which valued longer heads more highly. Ibn Ridwan recommended the binding of malformed heads in infants (in Wiberg, 1914/1996, p. 16). Gian Filippo Ingrassia, writing around 1550, noted that in this therapeutic sense custom, nurture, can become nature (1603, p. 61). Renaissance authors also noted the practice of cranial molding in the Indies.3 According to Giulio Cesare Aranzi, even the monstrous, sutureless skull could be cured, albeit with great difficulty: he cross-referenced this comment to Galens On Affected Places because it was a matter of knowing, predicting and curing affected places, thus setting Galens impossible type within the possible realm of a disease model (1579, p. 15). These ideas about therapy contrast with the biological determinism and incurability that dominate modern intellectual
3. Of course, abnormal head shape is today still seen as treatable with cranioplasty, not to mention New Age kinesiology, but it is no longer usually connected with intellectual development.

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disability. The idea of a medicina mentis goes back to Galen himself and his Stoic forebears. In Christianized Galenism, providential cure was a further possibility. A revival of interest in Ibn Rushd (Averroes) led some sixteenth-century authors to the idea that the parental act of generation endows each individual fetus with an informative virtue, with its own composition that differentiates among individuals (Jacquart, 1994). To us, this begins to look like an inherited rule of nature, something stronger than a changeable disposition. The intellective soul remains divinely generated, but the informative virtue may allow a degree of bestiality to enter it via the souls organic parts. It can cause conditions such as achondroplasia, in which the excessively large head will also signify a defect (depressio) of the rational soul (in Wielgus, 1973, p. 122). However, it was precisely the awareness of a continuity between fetus and living creature, suggesting for us a biologically determined personhood, that would more likely have suggested for contemporaries the creatures plasticity and have reinforced the belief that its moral-intellectual state was responsive to cure, medicinal or providential. As Santorio, the late summarizer of many of these arguments, pointed out, no impairment, even ab utero, can affect the individuals prior status as a rational being: the disposition is, in Aristotelian terms, accidental and not essential to being human (1632, p. 207). On the one hand, then, no intellectually disabled type, in the sense that we might understand, appears in Galenist medicine. On the other hand, cognitive impairment was nevertheless typical for some human types. It appeared in the psychological stereotyping of existing social groups such as women, non-Europeans, and the lower social classes. Ibn Ridwan had already said that women kept their hair as they got older because a womans brain has excess humidity, which damages intellectual functions (1523b, p. 12). Womens cranial sutures were narrower than mens and therefore had poorer drainage efficiency. According to Oddi, people who have narrow sutures, women for example, are somewhat crazy (dementiores) (1574, p. 122). Aristotle had said that women had smaller brains than men, and fewer sutures (1937, p. 155); Dryvere, drawing on Galens recently rediscovered Roman predecessor Aulus Cornelius Celsus (1772, p. 468), claimed that this deficiency gave women harder skulls (1547, p. 115). However, pioneers of Renaissance anatomy such as Andreas Vesalius claimed that womens skulls were not always different from mens (1543/1725, p. 15), and others, such as Caspar Bartholin in 1611, insisted that the number and layout of sutures was exactly the same in both (in Todd & Lyons, 1924, p. 327). As for size, dAbano referred to unnamed (and possibly nonexistent) ancient authors who had argued that women were wiser and more prudent than men and that since women also had smaller heads, smallness could therefore not be a defect. This was his chance to propose the opposite: that womens wisdom and prudence are just a devious cunning, not the proper masculine version (1565, p. 114). Luca Tozzi, writing toward the end of the seventeenth century (he was the last published commentator on The Art of Medicine) and quoting Aquinass assertion that people with small heads are impetuous and aggressive, used the smallness of the female head to clinch this point (1711, p. 28). Celsus (1772) had claimed that monstrous crania, devoid of sutures and thus abnormally shaped, occur more often in warm climates. He was talking about Ethiopians, who exhibited the same tendency to anger and impetuosity as women and the same hardness of the cranium (the street myth that black people have hard skulls survived through the twentieth century and may still be circulating today).4 This was taken up by Renaissance anatomists such as Ingrassia
4. Gratiolet, a leading anatomist of the nineteenth century, was still noting that sutural closure occurs earlier in Negroes and the lower races of mankind (in Todd & Lyons, 1924, p. 342), while Todd himself divided his comprehensive twentieth-century study of cranial sutures into separate sections for white and Negro stock.

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(1603, p. 65) and Alessandro Benedetti (1998, p. 242). Some doctors, claiming that Galens impossible type could exist in real life, located it in places where the inhabitants were exotic and different, such as the Indies (for example, Girolamo Cardano, in Hofmann, 1625, p. 216). Links between unusual structure and impairment of the internal senses appeared most starkly in terms of social class. The masses in general were the touchstone of deformity, physical and moral. The commentators most usual illustration in this respect was again Thersites, whom we have already seen adapted to various physiognomic and behavioral interpretations. He qualified for this role because he was seen as the only non-noble character in the Iliad to have a speaking role. His folly was linked directly by Santorio to the shape of his skull: In Homer the head of Thersites, because it is pointed and badly shaped, is called fatuus (1632, p. 191). Riolan, on the other hand, saw him as having a small head, which indicated rash and heedless judgement, on account of the paucity of spirits (1631, p. 41). Da Monte had a different angle again: Thersitess skull was of Galens unsuitably sutured X type, which led to him being not so much stupid as useless in all things, as having neither an anterior nor a posterior eminence (1554, p. 130). Da Monte added here several other types of skulls in addition to Galens, linking them to particular imbalances of elements and impaired operations of the animal spirits. Several of these were associated with social class. One was typical of wage-laborers (baiuli). Here the rear eminence may be sound, but something is lacking from the frontal one. This damages one of the internal senses, the imaginatio, which is located in the front ventricle and whose task is to apprehend information coming from the five external senses and to combine particulars; from here it goes on to damage the cogitatio, whose reasoning operations (discursus, ratio) are performed in the adjacent, middle ventricle. Second, there were slaves, such as Aesop. In him, the rear eminence was missing entirely, but the frontal eminence only partly so. This explained how he could be lazy and of weak motion but at the same time clever and very wise (ingeniosus et prudentissimus). Third, there was the contemporary jester, whose mix of intellectual and moral characteristics induced in da Monte a tone of disgust: The ninth [and lowest] grade has a small head, out of shape on both sides, lacking any eminence, and so in all operations they are the worst; foul and deformed, they are the most disproportional, and have bad inclinations (mores). Of these Ianelus, the Cardinal of Ferraras fool, had less wisdom than a dog. He was a mimic, with a crippled hand and a large head resembling a vegetable. He was quick to anger and always looking for a fight, now with this person, now with that. He did not know anyones name or anything at all, and I think he did not have a rational soul, since all his operations were like a dogs. (1554, p. 120) Read through a modern lens, this seems simply to be a picture of monstrosity set in intellectual terms. It must be remembered, however, that people like Ianelus (Little Johnny) had a formal slot in the landed household economy, and that as a whole they were recruited from social groupspoor peasants, people of short stature, black peoplewho were already assumed to have psychological characteristics corresponding to the jesters occupational role. Little Johnny was a historically recorded figure, whom da Monte had probably observed firsthand. These suggestions about gender, race, and class may seem like a historicist application of some modern clichs about identity. But while it is true that early modern psychology assumed the intellectual inferiority of everyone who was not a white upper-class maleso far, so modernit did not have as its ultimate reference point for this inferiority, as we do, a separate, statistically abnormal, intellectually disabled population. To put it another way, doctors of the late middle ages and Renaissance, and the social elite to which they belonged, did, in fact, see a population whose disability (which, in fact, they saw chiefly as moral) consisted in their being unable to think abstractly or reason logically, but that population was the majority: it was

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everyone except males of a certain social standing. Only later was a specifically intellectual element isolated (the moral aspect having been sublimated within it) and applied to a category whose degree of pathology was inversely proportionate to its size. On the one hand, the cognitive impairments organically linked to certain material states of the brain cannot easily be made to fit modern typologies of intellectual disability, while on the other hand, some of the impairments now seen as characteristic of intellectual disability were then characteristic of people occupying inferior social roles.5 The intellectual disability of the modern period, under whatever name, can thus be seen partly as a distillation of previously existing stereotypes of socially inferior beings in whom a degree of intellectual inferiority was inscribed. ANATOMY, MONSTROSITY, PERSONAL IDENTITY If, then, intellectual disability is essentially modern, did medicine merely receive it from the early modern politico-theological matrix in which it was born? Or were there elements within the medical mind-set itself that positively assisted in that reception? To answer this question, we need to look at (a) the changing relations between the natural, the unnatural, and the preternatural and (b) emerging discourses of personhood, and at the connections between the two. Impairments of the internal senses, as described by the commentators, were not objects of pathology in the same way that intellectual disability now is. They were simply unusual, unnatural only in the limited Aristotelian sense that their causes remained within the realm of nature. They were not preternatural, against nature. A simultaneous counter-current had begun, however, in which there was a conceptual fusion between the unnatural and the preternatural, and it is in this sense that we can occasionally find some ingredients of an emerging intellectual disability under the then-current terminology. In Galen, preternatural referred to causes of disease coming from the environment, from outside the human body. Early modern Galenists largely restricted these preternatural causes to God or, more often, the Devil. In the latter case, the cause did not just exist outside nature but ran counter to it. A utilitarian anxiety about consequences, in this case, of demonic activity in the world (expressed also in anxiety about witchcraft), was increasing during the period immediately before the scientific revolution of the later seventeenth century. In this period, the relationship between monstrosity and cranial morphology became closer. Galen had dismissed the possibility of a sutural pattern in which the length of the head becomes its depth (the extreme X-shape). For him, this meant that some brain material might be missing, in which case the creature could not live. The later theory of ventricular localization of the internal senses, however, created the possibility that a specific part of the brain might be missing. The effects might be limited to that part and thus less injurious. Certain Galenists claimed to have observed Galens impossible type of skull in living humans. DAbano said it might exist in some monstrous dwarf (1565, p. 120). Such beings were rare, more or less unviable (ut invitalia), but not downright impossible. Benzi subsequently claimed not only to have observed Galens impossible type in a child of four in Bologna, but to have measured the childs skull (1498, p. 20r). The evolution of impossibility into possibility seems, however, to owe much to the developments in anatomy launched by Vesaliuss De Humani Corporis Fabrica (1725). He claimed current empirical evidence of his own for a beggar going around in Bologna who has a square head somewhat broader than it is long, [and] in Genoa . . . a boy of about three whose head
5. In the twentieth century, Crookshank was still pursuing a theory that saw physical and mental homologies linking so-called mongoloid imbeciles with the inhabitants of Mongolia, orangutans, and the English working classes (1931, p. 329).

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sticks out on either side (p. 16). A child with the same shaped head could be seen wandering around Venice, deformed in other parts of his body; more significantly for us, Vesalius called this child (albeit not the others) amens, mindless, though what amentia may have meant to him can only be surmised in the light of my previous discussion. Hofmann, for example, paraphrasing Vesalius, named its chief symptoms as catarrhs and apoplexy (1625, p. 218). Since Vesalius opposed the idea of a link between cognitive faculties and specific cerebral ventricles, we must look elsewhere for an explanation of why he thought this a possible type. He may have insisted on its viability because he wanted to point out the variety of types and individuals, which was consistent with his Lutheran approach to the body as evidence of Gods authorship of each individual human (see Cunningham, 1997, p. 225). He also claimed, in a way that evoked Hippocrates, that head shapes differ from region to region because of differing practices in laying down infants to sleep. Several authors repeated the Bologna story, whether Benzis or Vesaliuss. The emphasis was usually physiological. Nevertheless, Vesaliuss psychological embellishment of the case of the Venetian boy was repeated by others. Gabriele Falloppio replaced amens with stolidus (1561, p. 4). Johannes Schenk extracted it from its anatomical context and introduced it into the existing genre of monstrosity literature, alongside routine lists of physiological monsters already familiar to the contemporary reader (1584, p. 25). He classified skulls without sutures or with the sutures obliterated with two-headed monsters, conjoined twins, and Blemmyes (a much-cited tribe of people with faces in their chests). He added to this list the completely mindless (amens) Venetian child, which he said was without sutures rather than, as Vesalius had it, of the extreme X-type. (This elision of the two types became common; Benedetti noted that in Padua at a public dissection we saw a solid, seamless cranium: such heads are known as dogs heads . . . and are said to be very firm and pain-resistant (1998, p. 244).) None of the other creatures on Schenks monstrosity list carried this psychological terminology, and in the monstrosity literature as a whole, it only made stray appearances. The phenomena, such as conjoined twins, among which Schenk placed the sutureless skull tended to belong in the category unnatural rather than preternatural or diabolic. Renaissance Galenism had placed Galens suitable H-shaped arrangement of sutures under its own heading of the natural (naturalis). The word natural did not necessarily indicate a stricter kind of categorization than suitable. And unnatural still signified, as it had done for Aristotle, an unusual and exotic manifestation of nature itself (Vesalius noted that sutures also close up in the skulls of old people), rather than an exclusion from it. However, at a certain (late) stage the unnatural pointy-head shapeclearly based on the commentary tradition discussed abovecame to be applied to other creatures that came from outside that tradition and had already long been thought of as preternatural. One such was the basilisk, an emblem of the devil. Of medieval origin, this hybrid of a cock with a serpent, which could kill you simply by its stare, made increasing appearances in the early modern period (by 1600, it was reported as killing people on a regular basis). Alexander Ross, author of a widely circulated catalog of freaks published in 1652, added to the existing conventional description a pointy head (p. 144).6 This example demonstrates the fusion between preternatural and unnatural, or at least a new confusion, about the boundary lines. Just as the preternatural basilisk acquired morphological characteristics from the unnatural types described by Galen, so there was a new hesitancy about the status of the latter. The two T-shapes, as well as the moderate X-shape, had
6. This is not particularly strong evidence for a process of change, since I cannot claim that this is the first time it happens. However, I have not read descriptions or seen drawings of the basilisk with a pointy head from before this date.

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been merely unnatural, whereas the extreme X-shape, being allegedly unviable, might have suggested preternaturality. But the Vesalian anatomists clearly saw the latter as occurring with a degree of regularity. What did this mean for its categorization in relation to nature? Schenk, as we have seen, placed it unreservedly in the context of the unnatural. Ingrassia reinterpreted unviable (invitalis) to mean unlikely to survive, but rather than categorizing this type as unnatural, he described it as quasi- [tamquam] preternaturaland brought in the ever-flexible Thersites to illustrate the point (1584, p. 64). Classification was uncertain in such cases. Vesalius himself had already displayed this hesitancy: The other unnatural head shapes can sometimes be seen even among perfectly respectable citizens, though one rarely finds them in cemeteries. However, they would be seen to occur often if we could investigate the cemeteries of people living in the Styrian Alps, since the inhabitants heads are deformed not only in this way but also in further ways that are more outlandish. (p. 16) By other, he clearly meant the T-shapes and the moderate X-shape. His train of thought here seems to pursue a continuum from these respectable peers of his to the oafish monstrosity of thyroid-deficient Alpine peasants, thus emphasizing the variety of types. Yet this same departure from convention, from the tripartite division of natural, unnatural, and preternatural, could be seen as the start of a bipartite mind-set. A polarization has begun, in which the unnatural shape is categorically uncertain; to use anachronistic terms, it has to be assigned as either normal or abnormal. The occasional addition of a cognitive terminology to cranial monstrosity in this process occurred at a time when, in any case, the distinction between unnatural and preternatural was beginning to fade. Degree of regularity is precisely what establishes abnormality for a modern physician or psychologist. The fusion of the unnatural with the preternatural is so complete in modern medicine as to be unrecognizable as such: today, they simply form a single category, the abnormal. Historically, the fusion coincided with the rise of natural history and a concern with the logical definition of species membership, as well as with new theories of personhood. The preternatural, that which lay outside nature because of its diabolic origins, when translated into a scheme of theologically justified natural history, might become that which lay outside the species. This anxiety about the borderline between humans and the other animals to some extent bridges the gulf between Renaissance and Enlightenment versions of the chain of being. It was no antiquarian whim that led the great Enlightenment (and Calvinist) physician Herman Boerhaave to republish Vesalius and his anatomist contemporary Bartolomeus Eustachius. The latter had opened his book on the anatomy of the skull with a blast against previous writers on anatomy who maliciously confused the cranial sutures of humans with those of apes. What else but malice, in its deepest theological sense of opening the way to atheism, could account for their blurring of the dividing line between humans and other animals? The new anatomists favored the empirical evidence supplied by dissection wherever it clashed with Galenist theory, even if they saw their work as defending that theory in its broader principles. Thus, Eustachius cast his opponents as anti-Galenists who, in respect of cranial sutures, perversely followed the ancient master without empirical justificationi.e., precisely where he had been wrong. It was well known, said Eustachius (following Vesalius), that Galen could only ever have dissected animals, so his description of the sutures was inaccurate. In humans, the sutures as drawn on the page most elegantly imitate the multiform lines of the geographer, whereas in apes they are obscure, so that for the most part they in no way or scarcely de-

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serve the name of sutures (1707, p. 151). Galens description fitted the simplicity of the simian skull. Sutures in the human skull are varied and individual, such that the two arms of the lambdoid suture will often be of unequal length (this variability from one individual to another, the key to the new anatomy based on observation and personal experience, explains the reference to geographers lines). It was precisely Eustachiuss need to keep humans separate from apes, on grounds of the individual anatomical variety of the former, that made him insist on the viability of Galens impossible type (I publicly dissected fifteen skulls in one day where the coronal suture was absent, 1707, p. 148). In the medieval bestiary, the monkey had been, like the basilisk, emblematic of the devil. The deceptive similarity of its sutural layout was not a similarity at all but a crude and ridiculous imitation of the elegant variety of the human skull. This point had a directly moral content for Eustachius. Again, it recalled the behavior of the jester. It also evokes modern tendencies in applied psychology to explain away the abilities of intellectually disabled people as mere imitation rather than the real thing. If Eustachius expressed moral difference in anatomical terms, another medical man, John Locke, in one of modern psychologys ancestral texts, expressed a similar moral difference in terms of the natural history of the mind. He defined changelings, a term just then coming to replace natural fool and echoing earlier accounts of children exchanged by witches in the cradle or born from the devils semen, as a separate species midway between humans and apes. In their case, the post-Cartesian and strictly demarcated species difference was that the body is of human appearance while it hath no rational soul (1975, p. 570). In this expression of theology as natural history, changelings came to have a fixed, permanent, birth-to-death identity based on their absence of reason. This identity was the obverse of, and perhaps a prerequisite for, the personal identity theory that Locke constructed for reasoning individuals whose species essence was moral man, and which he famously appended to the second edition of the Essay (Goodey, 2001). When the Renaissance da Monte looked at Little Johnny and when the proto-modern Locke looked at the changeling, neither was asking the psychologists question, What does an intellectual disability look like? but rather the theologians question, What would it look like for an apparently human creature not to have a rational soul? Da Monte asked it in the Galenist terms described above. Locke asked it in terms already framing the modern intellectual disability I outlined at the start: the human mind is a separate, autonomous realm of nature, an item in natural history; this natural history defines species with the strictness of logical classes; there is convergence between the unnatural and the preternatural (the beginnings of the modern abnormal); and there is a phenomenal-type account of personhood. In this sense, it may be that beneath the first of the above questions, with its scientific-looking appearance, psychology is still really asking the second. In that case, it is not the Renaissance conceptual models of cognitive impairment, even when matched to head shape and cranial sutures, that show evidence of historical continuity from then till now; it is medical writers discussion of and attitudes to monstrosity that do so. The continuity may therefore be less scientific or conceptual than anthropological: something in the mind-set of the doctor. Of course, doctors eventually jettisoned Galenist medicine as such.7 As for physiognomics, to the extent that it survived, it strayed from classical tradition and took its own path. And the whole point of Lockes doc7. Some of the issues were still pursued later but translated into developmental terms. For example, in the late nineteenth century, there was still an argument as to whether microcephaly was caused by premature cranial synostosis or whether premature synostosis is a consequence rather than the cause of imperfect brain development. Those who believed the first hypothesis had a habit of performing craniectomies, sometimes fatally (Shuttleworth, 1881, p. 241).

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trine of the changeling was that it refutes physiognomics. A deformed body is precisely not a sign of deformed character; the mind is quite capable of being deformed on its own account. Nevertheless, the new conceptual model of a disability described in strictly intellectual terms emerged partly with the aid of older, conventional physiognomic discourses; and if it did so, it was because of a certain shift in the relationship between doctors and monsters. One example is Nicholas Culpepers English translation and commentary on Galens Art of Medicine published in 1652. This was the same year in which Ross gave the basilisk a pointy head, and also the year when a demonic sense was introduced in the changeling through the English translation and publication of Luthers Table Talk (see Goodey & Stainton, 2001). Culpeper more than once interpolated fools into Galens text (that is, not merely in his own accompanying commentary). Galen had simply said, for example: A small head is the proper indication of a poor brain condition. A large head, however, does not necessarily indicate a good condition. But if it has become strong because the power residing in it has created matter that is useful as well as abundant, that is a good sign; if however because of abundance alone, that is not a good sign. Culpepers translation ran: A Very smal Head is a proper Indication of a vicious Brain, and yet a great Head doth not necessarily declare a strong Brain; If there be not capacity enough in the Skull to hold the Brain, or a sufficient quantity of Brain, the Man must needs be a Fool. (Culpeper, 1652, p. 11) It is not clear whether this was Culpepers historiographical assumption (he supposed Galen would have constructed a typology of fools if asked to clarify), or whether it was an organic development of late Galenism (in straying from translation into exegesis, he thought he was improving on the original). Culpepers other works show that he was quite capable of faithful translation. Nor, once again, can we really tell whether the symptoms that Culpeper saw in his fool would have had much in common with those we identify in todays intellectual disability. His novelty was simply to introduce a substantive person or type into texts that previously had only contained strings of adjectives, whose range of reference was mainly to melancholy and mental illness, occasionally fleshed out by some quasi-mythical illustration. Along with the deterministic implications of must needs be, perhaps absorbed from theological discourses of predestination, Culpepers substantive fool already resonates with the changeling and with the theory of personal identity that was to achieve fuller expression with Locke. CONCLUSIONS It may now be possible to look at some longer-term pattern in these conceptual shifts. I am still not convinced that the premodern doctor would have recognized as his fools the intellectually disabled people I sent him in the time machine. On the other hand, the notion of rupturethat medicines conceptual and diagnostic approach simply stops and starts anew in the late seventeenth centuryis clearly not right. I have suggested that for evidence of some continuity in the conceptual history of intellectual disability, we should look not at the person so labelled but at the mind-set of the doctor, where the image of disability has been molded and remolded. The Hippocratic doctors simply talked about four kinds of arrangement of the sutures. Galen added a hierarchy of values: one kind is suitable or exemplary, three are defective, and he criticized his pred-

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ecessors for not describing a fifth type that would be monstrous; even so, said Galen, this fifth type can only exist in the imagination. Some Renaissance Galenists then amplified this picture with the claim that they had actually seen an example of this type even if it didnt live for long: they can exist in reality. Someone who says There isnt is followed by someone else who has to say, Yes there is. The urge to seek out monstrosity constitutes the actual process of its invention. Thus too with the early historiography: Benzi cited his predecessor dAbano as saying that he had seen one when in fact dAbano had only said that it might exist (1565, p. 20r). This dialectic consists of an ever-recurring exhaustion of doctors state of wonder at the separateness of monsters from the rest of nature, and a consequent urge to propose and explore boundaries beyond which to make new, outlandish discoveries. Medicine, over the long historical term, has had a shamanistic role: doctors have revealed the existence of the invisible or inconceivable, and in so doing they have reinforced their right to decision-making powers over inclusion and exclusion from nature, not to mention social institutions. The blockhead is inconceivable (Hippocrates); the inconceivable becomes conceivable but unviable (Galen); the conceivable but unviable becomes viable but wondrous (Benzi). And once late nineteenth-century physicians claimed to see sutural anomalies in the skulls of people with Down syndrome, the viable but wondrous had became the mundane but abnormal (Shuttleworth, 1881).8 In this passage from inconceivable to merely pathological, the wonder of nature is constantly lost and then rediscovered in precisely the form that was the previous limiting case. The limiting case would be a wonder if it could exist, then, presto, it does. The dialectic I have described began with anatomy alone. As it crossed the historical divide of the late seventeenth century, fools or changelings of demonic origin entered the mind-set. Culpepers text itself is an example of how the anatomical blockhead of the Renaissance became the metaphorical blockhead of modern colloquial discourse. The very act of translating a major teaching text, the Ars Medica, into English was a radical move.9 In his preface, he castigated the elite College of Physicians that ruled medicine at the time, complained about their insistence on Latin as a way of preserving their social and political position, and scoffed at their obscurantist theorizing and calculated esotericism. He applied the trope of monstrosity and species exclusion precisely to this professional elite, to their reactionary defense of that Monster TRADITION, who seldom begets any Children but they prove either Fools or Knaves, and this makes them so brutish . . . One of their obscurantist tricks was their custom of putting a deformed skeleton on show, a monster in the first room, in order to impress new patients (Culpeper, 1651, p. 139). The irony of the situation is that Culpeper himself, when he inserted his fool into Galens text, was contributing to that sideways branching of the dialectic that was to continue with Lockes changelings. A monstrosity eventually came about that belonged in a separate and strictly intellectual sphere, and which had a much more rigorously determined and excluded identity than the monstrosity of the skeleton in the traditional doctors waiting room. Far from being, as the latter had been, a demonstration of Gods power to endow nature with a rich tapestry of wonders (monster comes from monstrare, to show), monsters characterized by a permanent incapacity for reason demonstrated now the power of the devil. In this lies the modernity of intellectual disability.
8. Shuttleworths (1881) photograph of the brain of an idiot of the mongoloid type may also have been intended to show a skull in which there is only one suture (Wellcome Institute for the History of Medicine, Historical Images Collection V0030015). 9. The Method of Healing had been translated into English before, but The Art of Medicine, unlike the former, was one of the two main textbooks on every curriculum (the other being Ibn Sinas Canon) and thus impinged on the politics of medical education.

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