Madness and Civilization Summary and Review

by Michel Foucault
Has Madness and Civilization by Michel Foucault been sitting on your reading list? Pick up the key ideas in the book with this quick summary. If you’re curious about modern philosophy, there’s a good possibility you’ve heard the name of the French thinker Michel Foucault. He’s one of the more popular characters from the age of post-modernism and continental philosophy. Having worked in a mental institution and dealing with his personal psychological problems, Foucault’s intense interest in the history and usage of psychology motivated him to write Folie et Déraison: Histoire de la folie à l'âge classique, or Madness and Civilization. As Foucault details, our relationship with mental illness and how we perceive, interpret and treat it has changed considerably – though in some ways we’ve continued to be firmly ignorant. Foucault concentrates principally on the end of the Middle Ages and the years surrounding the Enlightenment, which started during the early to mid-1700s. It’s through this period that Foucault recognized “great confinement”; when the undesirable components of society – including the impoverished, unlawful and “madmen” – were corralled and locked away out of public view. It took hundreds of years before people with mental illnesses were treated any differently than criminals or even animals, but as we’ll notice in this book summary, our knowledge of the mind would eventually develop. In this summary of Madness and Civilization by Michel Foucault, you’ll find out:
  • how criminal and “insane” people ended up in the same hospital;
  • how early hospitals were like to zoos; and
  • which Quaker permanently altered how we treat people with mental illness.
Note: Madness and Civilization was published in 1961. Reflective of that is the language used to describe mental illness and mental disorder. Terms such as “mad” are sometimes used in cases where they best represent Foucault’s text.

Early Mental Health Institutions

During the late Middle Ages, from 1250 to 1500 in Europe, “madness” was not defined in the same way as what it shifted to hundreds of years later. People with psychological problems were basically considered  to be “different.” Some were even seen as possessing a wisdom that exhibited the boundaries of reason. Throughout this period, most people with a mental illness roamed freely, as long as they were in someone else’s backyard. If an alleged “madman” was detected in a European town, he’d be sent to a sailor or merchant who’d leave them in another city or a sparsely populated area of countryside. This custom was especially prevalent in Germany. In fifteenth-century Nuremberg, records reveal how 31 of 63 mentally ill people were evacuated from the city in carriages and boats. And in Frankfurt, at the end of the fourteenth century, seamen were ordered to round up and remove any people seen wandering in the nude. The practice of shipping off the mentally ill is where the phrase, “ship of fools,” comes from, an expression popularized in literature and other artwork over the years. Several works point to the Narrenschiff, or “ship of fools,” which sailed the waters of the Rhine and Flemisch canals, taking away the city’s “madmen”. Hieronymus Bosch, the famous Dutch painter, captured this image in his painting, The Ship of Fools, created between 1490 and 1500. It wasn’t until years later, after the decline of leprosy in Western Europe, that people with mental illness started to be detained. Leprosy is a contagious disease affecting the skin. When it spread across Europe, patients were restricted to specific facilities termed lazar houses, found on the outskirts of cities. When leprosy outbreaks receded in Europe, these facilities found a new direction in detaining criminals, vagrants and those with mental illnesses. It’s almost unsurprising then that these new detainees were started to be viewed at as carriers of the disease. Just like medieval societies had come to marginalize and stigmatize the “leper”, classical age societies did the same to these people – thereby linking the word “madness” with being an outcast. But it wasn’t only lazar houses that were taking in people with mental issues. In the early eighteenth century, cities started to hold such people in secured locations, like the tower within the walls of Caen, France, recognized as the “Tour aux Fous.”

The Opening of General Hospitals 

By the start of the seventeenth century, idleness – or the perceived scarcity of interest in working – had grown to be a characteristic that the ruling classes not only hated but also deemed it dangerous to society. Consequently, the authorities had to find a method to control this behavior and also shield it from the public eye. The primary role of the police, which first emerged in European countries around that time, was to ensure that impoverished people worked. In the same spirit, the Hôpital Général, or general hospital, was not designed to treat the ill, but to restrict the idle and the unwanted. Foucault looks at that development as the origin of the “great confinement.” In 1632, one of the most notable lazar houses, St. Lazare, was transformed into a general hospital. In 1656, France’s king, Louis XIV, inaugurated the opening of Paris’s general hospital. The inauguration accompanied a decree forbidding panhandling in the city, and anyone caught would be required – by a militia of archers no less – to transfer into the hospital. Developments of this nature were not limited to France. Other European countries were making similar changes in how they treated unwanted people, and soon a significant population was restricted to these institutions. Several years after opening its doors, Paris’s general hospital became home for 6000 people – one percent of the city’s population! This included beggars, petty criminals, social outcasts, and those who struggled with a mental disorder. To combat laziness and unemployment, the inhabitants of general hospitals were forced to work and produce goods. In Paris, numerous attempts were made to convert some of the buildings of the hospital into factories. In Tulle, residents carded and spun wool for a local businessman. The advantages of those work policies were questionable at best considering their economic output was less than the value of their confinement. Firstly, the great confinement was a representation of the moral standards of the ruling classes, including the church, state and bourgeoisie, and the capacity to force their standards on the disadvantaged. It also indicated the moment when the word “madness” started to be correlated with an incapacity to work and integrate into society.

Treatment of “Madmen” 

When hospitals were first built, the people there were petty criminals, homeless and other social outcasts. In most cases, this confinement was a means for unwanted elements of society to be put out of sight, thus enabling the authorities to preserve the illusion that there aren’t problems in the public sphere. However, these hospitals weren’t just a method for the authorities to evade scandals, they were a way for families to avoid receiving undesired attention. In the Middle Ages, if someone was indicted for criminal behavior, they would hold an open trial where the accused was asked to openly admit to their crimes. Obviously, this could surely bring disgrace to the families of the accused, which is why hospital confinement presented as an appealing alternative. In numerous cases, it could be arranged that the accused was placed in a hospital without a public trial. Officials were pleased that as the streets were free from vagrants and “undesirables”, and families were absolved from any embarrassments. For those being detained, though, life was not exactly ideal. Between the seventeenth and eighteenth centuries, science and medicine had yet to comprehend that those who were considered “mad” were really being affected by a class of sickness or psychological disorder. Unfortunately, such people were frequently handled like exotic animals. At the time, people with mental illnesses and disorder only accounted for ten percent of the restrained population, and unlike petty criminals and the hidden away, they were put on display for inquisitive spectators. At the Bicêtre hospital just south of Paris, this exhibition took place every Sunday and remained until the rebellion of the French Revolution. An early leader of the revolution, Honoré Mirabeau, explained this disgusting practice in his book Observations D’Un Voyageur Anglais (1788). He wrote, “madmen were shown like curious animals, to the first simpleton willing to pay a coin.” Also, until 1815, London’s Bethlehem hospital opened their doors to paying customers on Sundays, so that anyone paying could gape at these people. Potentially violent “madmen” were regularly chained to the walls with shackles around their ankles, wearing only hospital gowns. At a hospital in Nantes, France, they were put in individual cages. Strangely enough, the hospital staff thought that these people must be used to pain, the cold and various discomforts and could only be tamed with harsh regulation. These conditions were seen in hospitals all over Europe.

Separating People with Mental Illnesses From Criminals

When “madmen” populated hospitals alongside the petty criminals and convicts, the circumstances of the detainment were poor for both groups. By the eighteenth century, with the rise of the Enlightenment, there was an increasing public concern regarding mistreatment. But which group of people were they truly worried about? Numerous facility directors supervising the confinement were primarily troubled with the criminals’ safety and accordingly asked they be segregated from those with a mental disorder. Finding the outcries and chaos caused by them disturbing, in 1713, the director at the Brunswick detention center in Germany required that both groups were to be kept separate. However, from the late eighteenth century, and continuing into the nineteenth, concern moved toward those with mental ailments. In France, Germany, and England, the public officials visiting the hospitals were horrified by the conditions that the patients were subject to. German doctor, Johann Christian Reil, fretted saying, “the madmen are thrown, like state criminals, into dungeons where the eye of humanity never penetrates.” Reil’s criticism was backed by French psychiatrist Jean-Etienne Esquirol in the early nineteenth century, who claimed that “there are a few prisons where the raving mad are not to be found; these unfortunates are chained in dungeons beside criminals. What a monstrous association.” But often, the underlying causes to rethink these practices of restraint were economically related. When the ruling classes started the great confinement in the late seventeenth century, the purpose was to sustain the status quo by not only keeping idle people away but also to make them work. Nevertheless, at the time, the price of confinement outweighed their economic output. Yet, at the turn of the eighteenth century, with the industrial revolution brewing, economic thinkers were reconsidering the advantages that could be produced by the idle labor lying behind those hospital walls. This time, the authorities could realize that it was the petty criminals and the needy who were the true source of low-cost labor, not the “madmen”. They recognized that people with mental illness would only delay the workforce, so they grouped them away from inmates who could earn their keep and be put to work.

Madness as a Physical Ailment or Psychological 

By the end of the Middle Ages, doctors still thought that there were only physical reasons for mental disorders. The common view was that our bodies held four “humors” that were accountable for each ailment and mood that emerged: black bile, yellow bile, blood, and phlegm. Initial treatments for mental illness focused on measures to counteract these conditions and incorporated exercise and nutritional regimens, fresh or seawater baths and cold showers. There were also four different types of mental disorders associated with the humors: melancholia, mania, hypochondria, and hysteria. Being that melancholia and mania were the oldest mental disorders to be diagnosed, their treatments continued to be unchanged since the days of ancient Greece. Melancholia was similar to the way that we look at depression today, while mania was deemed as its opposite – a state of continuous overexcitement. As for hypochondria and hysteria, these were comparatively newer disorders, having appeared in the seventeenth century. Hypochondriacs were people who thought they were ill even though there were no ailments actually observed. Hysteria was utilized as an umbrella term to cover a variety of mental disorders affiliated with over-excitement and emotional instability. It should be noted that hysteria was first linked to female patients, the expression descending from hystera, the ancient Greek word for “uterus.” In the seventeenth and eighteenth centuries, throughout what Foucault regarded as the “classical period,” the knowledge of mental illnesses or disorders eventually grew beyond physical causes to incorporate psychological ones. In some private practices, like that of Portuguese-Dutch physician Zacatus Lusitanus (1575-1642), psychological treatments were added to the existing collection of physical treatments. One method was to “awaken” patients to ideal morals and behaviors by trying to instruct them on acceptable behavior like they were children. In other cases, delusional behavior was treated with theatrics, like putting a heavy lead ball on the head of a patient who felt like he didn’t have a head. The pressure and great discomfort were intended to make the patient understand that they did really have a head. While more tactful psychological strategies would begin to be developed, at the time the notion of psychology had yet to be created. When these new treatments were being produced, they weren’t looked at as fundamentally distinct from physical treatments, though in hindsight we can understand that they were the beginning steps to treating the mind uniquely from the rest of the body.

The Modern Psychiatric Institution 

While people with psychological issues were isolated from other victims of the great confinement, and treatments for these disorders were just originating, the first modern “mental asylums” were built. A lot of the credit for producing these early institutions goes to renowned French physician Philippe Pinel and English philanthropist and businessman William Tuke. Tuke’s facility in rural York, England, was recognized as The Retreat – opening its doors in 1796. Since Tuke was a Quaker, his institution also followed a particular morality that eliminated the barbaric dungeons and abusive practices. Instead of using physical discipline, the wardens were instructed to employ reason and discussion when a patient presented with undesirable behavior. In France, Philippe Pinel had previously freed those with mental illnesses from their physical bondage and torment. Three years before The Retreat opened its doors, Pinel discarded the chains from the Bicêtre hospital in Paris and shortly did the same at the Salpêtrière hospital. Furthermore, he put an end to the harsh remedies of bleeding, purging and blistering, substituting them with more humane and psychological procedures. Under Pinel’s administration, patients were more conscious of their actions and urged to reflect on their misbehaviors. Thanks to Pinel and Tuke, patients weren’t subjected to that level of abuse any longer. However, these institutions were continuing to reinforce the values and power dynamics of the bourgeois society, but this time, the relationship between the staff and the inmates was more of a father-child dynamic. Additional advances in how people with psychological problems were handled included replacing the previous prison administration with actual doctors. From the end of the eighteenth century, any facilities accommodating mentally ill patients were required to have a medical certificate. Now, doctors had a pivotal role in these modern institutions, regularly attending patients while monitoring their health and progress. Moreover, it was in these certified institutions that the contemporary psychiatric practice bloomed. Before the late eighteenth century, the study of “madness” wasn’t developed enough to be deemed its own field of medicine. But when the asylums were created, the discipline of psychiatry was able to grow as a science in its own right. Finally, treatments could be experimented with in a controlled setting, and empirical evidence could be obtained.

In Review: Madness and Civilization Book Summary

The key message in this book summary: From ancient Greece to the Enlightenment, and ultimately to the 1960s, when Foucault wrote Madness and Civilization, the comprehension of “madness” in European society evolved significantly. Hundreds of years ago, those with mental illnesses were forced out of sight and locked away alongside the poor, criminals and others considered to be “unwanted”. Authorities exploited the incarcerated community as cheap and idle labor, and the treatment was oftentimes cruel and dominating. Eventually, psychiatric asylums were designed and those with mental health issues gradually started to be treated more humanely. Slowly, the approach to mental illness grew to be rooted in psychology.