Foucault, Michel. Madness & Civilization: A History of Insanity in the Age of Reason. New York: Vintage Books, 1988.
Chapter Five: Aspects of Madness
Foucault analyzed different conditions seen in the eighteenth century as forming madness. He explored the ways in which doctors and theorists of madness described the causes and effects of mental illness. To do this, Foucault drew from the history of medicine. Up to the seventeenth century, causes of melancholia remained fixed within a tradition of the four humors. The tradition of the humors that Foucault discussed were a central part of early modern medicine. Doctors believed there were four humors—blood, phlegm, choler, and black bile. The melancholic personality type was thought to have too much black bile. There was a shift in thinking. The result was that the causality of substances increasingly was replaced by a movement of qualities. Qualities, which can be affected by circumstances, organized and integrated melancholia (a patient’s mental state). The idea of partial delirium increasingly disappeared as a major symptom of melancholiacs and was replaced by qualitative data such as sadness, bitterness, a preference for solitude, and immobility. The analyses of mania followed similar principles to the analyses of melancholia. In the eighteenth century, most believed that mania opposed melancholia, but both were believed to be caused by a movement of animal spirits. However, this was replaced by an explanation of tension in nerve fibers. Objects did not present themselves as real to the manic and a psychological explanation replaced ideas of humors and tensions. Thomas Willis (an English physician) was credited with discovering the alternation of mania and melancholia. Another key shift was the idea that the two conditions alternated within one person (modern day manic-depressive illness). Foucault discussed hysteria and hypochondria. Two problems arose in studying these conditions. The first of which was, to what degree was it legitimate to treat them as forms of madness? Remember, that madness was a state of being linked to unreason and not a mental disease. Secondly, were we entitled to treat them together “as if they constituted a virtual couple” (p. 136) similar to how melancholia and mania were treated? During the Classical period, hysteria and hypochondria were seen as mental diseases. Two lines of development existed during the Classical period for hysteria and hypochondria. The first was that they were a “disease of the nerves” and secondly, they were “diseases of the mind” such as melancholia and mania. Hysteria was a deceptive disease because it had various symptoms. Doctors said it affected women more because they had “softer” bodies. Until the end of the eighteenth century, the uterus and the womb remained present in the pathology of hysteria. The idea that the womb rose above its place was replaced by the idea that spirits moved chaotically within the body. It was believed that the sympathetic sensibility of women predisposed them to the “vapors” and nervous disease. Too much sensibility resulted in unconscious shock. A person could fall ill from too much exposure to outside, worldly stimulation. For the first time, outside influences on the body became important. Hysteria and hypochondria were diseases that resulted from lifestyle and not an imbalance of the interior parts of the body. The nineteenth century saw the “complete identification of hysteria and hypochondria as mental diseases” (p. 158). Psychology and morality now contested the same domain. Nineteenth century scientific psychology was now possible.
Chapter Six: Doctors and Patients
The therapeutics of madness did not function in a hospital because in this context, the focus was on “correcting.” During the Classical period, treatment continued to develop and focused on curing the whole individual, body and soul: “his nervous fiber as well as the course of his imagination” (p. 159). Physical cures developed from moral perception and a therapeutics of the body. Foucault listed these cures and their philosophies. The first was Consolidation. Beneath the apparent violence of madness, there was always an element of weakness, “an essential lack of resistance; the madman’s frenzies, in fact, are only a passive violence” (p. 160). A force needed to be found in nature to reinforce nature. Lange recommended that animal spirits be subjected to sensations and movements that were both agreeable, measured, and regular (pp. 160-61). Iron was thought to be the best solution. The second cure was Purification. Madness elicited a series of therapeutics that were intended to purify. The ideal was total purification. It consisted of substituting clear, light blood for “the melancholic’s overcharged, thick blood, encumbered with bitter humors” (p. 162). Some even thought that skin diseases such as scabies, eczema, or smallpox could cure madness. The principle task, however, was to dissolve the fermentation in the body. To accomplish this, the chief agent used was bitters. Coffee was often used as was tonic (quinine). Soap products produced effects because of soap’s dissolving powers. Soluble tartar was recommended when soap didn’t do the trick. Vinegar was used. The third cure is Immersion. Here two themes were present: ablution (washing) and immersion, which modified liquids and solids. Water was the key element here as it served as “a universal physiological regulator” (p. 167). In the Middle Ages, the traditional treatment of a manic was plunging them into water. From the end of the seventeenth century, the water cure of purification was one of the major therapeutics for madness. Hot water was believed to have the risk of feminization since it lead to relaxation, general humidity, and softness which were all traits of women. It was also believed by some that cold water could do the same. At the end of the eighteenth century, the powers of water began to wane. Because water had so many values, it could confirm anything and cancel anything. The shower was used in the eighteenth century and the beginning of the nineteenth century in asylums in an effort to purify the madman. The fourth cure was Regulation of Movement. Madness was the irregular agitation of animal spirits and also the immobility of limbs and ideas. Walking, running, horseback riding, and sea voyages all were thought to help restore movement. All of these means of therapeutics were organized around two fundamental themes: the subject must be restored to their initial purity and must be wrested from his pure subjectivity in order to be initiated into the world. These techniques lasted longer than their efficacy; when madness received psychological and moral meaning, they remained.
A psychological element seemed to be present in classical techniques. Fear was one passion that was used to treat madness. It diminished the excitation of the brain. Anger was also used and it was believed that it gave the nervous fibers more vigor and restored their lost elasticity. It was not valid to use the distinction between physical medications and psychological or moral medications during the Classical period. The difference only began to exist when fear was no longer used as a method for arresting movement but as a punishment. “In short, there always existed, throughout the classical period, a juxtaposition of two technical universes in the therapeutics of madness. One, which is based on an implicit mechanics of qualities, and which addresses madness as essentially passion—that is, a certain compound (movement-quality) belonging to both body and soul; the other, which is based on the discursive movement of reason reasoning with itself, and which addresses madness as error, as double inanity of language and image, as delirium” (p. 184). Three configurations existed. 1. Awakening: A need existed to tear the delirious from quasi-sleep. Awakening could be violent or proceed from wisdom. Slowly, authoritarian awakening became only a return to the good or moral law. 2. Theatrical representation: This appeared to be opposed to awakening. Here, therapy operated in the imagination. It continued the delirious discourse. Theatrical representation drove out the madness of delirium. 3. The return to the immediate: If madness was an illusion, the cure of madness could be brought by its suppression. Delirium was contradicted by nature. But the return to the immediate was not simple or absolute because madness was the experience of the most basic human desires. Nature had a fundamental power in the suppression of madness; it could force man from his freedom. In nature, man was freedom from social constraints and passion, but he was bound by a system of natural obligations. A liberation of madness was possible in which madness was opened to the constraints of nature. But the return to the immediate was effective only if the immediate was controlled.
The Classical perception of madness was reduced to the moral perception of madness, which was the core of the nineteenth century positive, scientific, and experimental concepts. This change began in the techniques of cure. Psychology was born as a sign that madness was detached from truth (unreason) and was adrift.
Freud studied madness at the level of its language. He restored the possibility of dialogue with unreason. Psychology was not involved with psychoanalysis; rather, it was the experience of unreason that psychology was supposed to mask.
Chapter Seven: The Great Fear
For the first time since The Great Confinement, the madman had become a social individual. By letting madmen back into the light, classical reason admited its closeness with unreason. Reason allowed people to drift into the margins, but fear and anxiety were close. People had a fear of being confined. Confinement was seen as the birthplace of evil. People feared contagion from these places. It was feared that the atmosphere “laden with maleficent vapors” would infect entire cities with “rottenness and taint” (p. 204). Houses of confinement were seen as sites of corrupted air and old fears of leprosy seemed to synthesize unreason with the medical universe. The eighteenth century reform movement sought to organize and purify the houses of confinement. “The hospital, the house of correction, all the places of confinement, were to be more completely isolated, surrounded by purer air” (p. 206). Morality and medicine tried to defend themselves against the dangers of confinement. People wanted asylums where unreason could be contained without a threat to the spectators who wanted to watch the spectacle. The Classical period confined not only criminals and madmen, but also the fantastic. In the Classical period, awareness of madness and unreason had not separated from each other. The fear of madness grew at the same time as the fear of unreason so the two worked to reinforce each other. Concern grew that the more man perfected himself, the more delicate he became. The threat of madness was ever-present. Foucault discussed madness and liberty. Madness was seen by other writers as the result of liberty enjoyed in England. It was thought that liberty alienated man from the essence of his world. Religion was suspected of arousing madness. Old religion was a positive force, but modern religion eventually allowed madness to function freely. Civilization was a milieu suitable for the development of madness. The progress of knowledge allowed for a mania for study and dangerous excitement of the mind to develop. Sensibility also detached man from feeling because it was a sensibility “no longer controlled by the movements of nature, but by all the habits, all the demands of social life” (p. 218). Novels and theatre excited people in a dangerous way. “The novel constitutes the milieu of perversion, par excellence, of all sensibility; it detaches the soul from all that is immediate and natural in feeling and leads it into an imaginary world of sentiments violent in proportion to their unreality, and less controlled by the gentle laws of nature” (p. 219). The eighteenth century developed a new range of concepts around madness. In the sixteenth century, the secrecy of madness related to sin and animality. Now madness was situated in a place where man’s relation to time, sentiment and other people was altered.
Chapter Eight: The New Division
The “new division” that Foucault discussed was the split that emerged between madness and other forms of confinement in the late eighteenth century. At the beginning of the nineteenth century, psychiatrists and historians condemned confinement. The age of positivism claimed to be the first to dissociate the madman from the criminal. The nineteenth century felt that madmen should be treated better than criminals and the eighteenth century felt that prisoners did not deserve to be treated like the insane. The consciousness of madness was transformed in the eighteenth century within the context of confinement. A new awareness of madness came from within confinement. Madness was denounced and isolated. The presence of the mad became an injustice for others. At the same time, confinement suffered another crisis from within. Poverty became an economic phenomenon, it had a necessarily role in life because it made wealth possible. The pauper now had a place in society unlike in the mercantilist economy. Confinement was an economic error because poverty had to be suppressed by removing or maintaining a poor population. The need was to use the poor for the labor market. Poor people could be put to work and therefore confining them was a mistake. Confinement could be criticized for its effects on the labor market and for the way it was financed. Setting aside wealth to pay for confinement actually led to an increase in poverty. The necessity of confinement disappeared in the eighteenth century. People no longer knew where to situate madness. There was a need to separate the insane from criminals. An ambiguous need existed to protect the population from madness and to give it special treatment. There was great confusion over how to determine the place of madness within a social sphere that was being restructured. Reforms intended to treat the mad, but there were no facilities in place for this treatment. Problems with madness and confinement arose from social uncertainty. As society changed, the role of the madman had to change along with it.
Chapter Nine: The Birth of the Asylum
Foucault suggested that the images of asylums are a strategy aimed at showing psychiatry as a positive force that could understand and cure the problem of madness. But this was merely a facade and Foucault dug deeper to see what was really happening. Foucault chose two people to represent the development of the asylum: Philippe Pinel and Samuel Tuke. Tuke was not a philanthropist. He founded the York Retreat as a rural, Quaker institution. This institution was focused on enlightenment through self-examination. He saw the exercise of religious principles over the mad as a cure. Patients were not locked up or chained away. Instead, their keepers reasoned with them. The aim was an attempt to awaken the madman’s conscience. Work was important to Tuke. In the asylum, work was deprived of any productive value, but it was imposed only as moral rule and an engagement of responsibility on behalf of the patient. Through a combination of guilt and observation, the madman began to behave in a normal way. Observation became a form of control. Because he knew he was being watched, the madman restrained his behavior. Observation was related to judgement. Those doing the observing would be in the position to judge what was good or bad, normal or abnormal. Thus the combination of observation and judgement made the modern science of psychiatry possible: “The science of mental disease, as it would develop in the asylum, would always be only of the order of observation and classification” (p. 250). It was not based on dialogue until the development of psychoanalysis. Everything at the Retreat was organized so that the insane were transformed into children. The concept of family became important as it “placed the patient in a milieu both normal and natural; in reality it alienated him still more: the juridicial minority assigned to the madman was intended to protect him as a subject of law; this ancient structure, by becoming a form of coexistence, delivered him entirely as a psychological subject, to the authority and prestige of the man of reason, who assumed for him the concrete figure of adult, in other words, both domination and designation” (pp. 252-253). The family became normal and reasonable. Pinel’s asylum was the opposite of Tuke’s in terms of religion. Pinel condemned religion as a dangerous irritant and thought it to be a potential cause of madness. He aimed to enforce moral standards that drew from the outside world on the madman. The asylum denounced everything that opposed the essential virtues of society. Ignoring or exceeding the world’s morality became madness. The social values of the family and work reigned in the asylum. Pinel’s asylum was a place where insanity as social deviancy was eliminated. The life of the patient was organized so that moral syntheses could operate in three ways. First, keeping the madman silent confined him and shamed him in front of others. Second, mirrors allowed madness to see itself. By causing the mad to recognize their condition, Pinel thought he could cure it. Third, madness was called upon to judge itself and was judged constantly by an invisible tribunal. The system of judgement and observation was supported by the appearance of the doctor-figure. Madness had now become a medical complaint, in the sense that the authority of science and medicine justified the treatment of madmen in asylums. The doctor-figure developed a great power over his patients. Tuke and Pinel opened the asylum to medical knowledge. The presence and words of a doctor-figure were often enough to illicit a cure. Psychiatry assumed priority for the first time. Positivism imposed itself more on medicine; the doctor became more powerful in the patient’s eyes. All of the nineteenth century psychiatry converged on Freud because he attempted to recognize the importance of the doctor-patient couple. Freud transferred Tuke and Pinel’s structures to the doctor. The doctor was key to psychoanalysis.