Madness in historical perspective ================================= * Andrew Scull Four decades have past since I began to work on the history of psychiatry, examining the rise of the asylum in Victorian England and the transformation of “mad-doctors” into a profession that eventually called itself psychiatry.1 In 1970, most academic and elite psychiatrists in North America thought that madness and meaning were intimately intertwined. Psychoanalysis had initially made inroads in America following Freud’s visit to Clark University in 1909. Hitler’s persecution of Jews led to an influx of refugee analysts from the early 1930s onward, and World War II provided a further impetus for psycho-dynamically oriented psychiatry — in part the fortuitous consequence of the appointment of the psychoanalytically inclined William C. Menninger as chief of psychiatry in the US Army, and in part the impact of the link between modern industrial warfare and mental breakdowns. The existence of mass psychiatric casualties in the military gave new credibility to theories of mental illness that linked its origins to the social and the psychological. Between 1945 and the 1970s, psychoanalysis occupied the commanding heights (such as they were) of psychiatry in the United States. Freud’s doctrines also heavily influenced popular culture during these years: the visual arts; literature and drama; advertising; and that quintessentially American dream factory, Hollywood. When it came to understanding mental illness, most pointed to the existence of half-murdered memories and repressed traumas, whose pernicious effects on the human psyche surfaced in all sorts of heavily disguised but deeply disturbing and distressing symptoms. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/188/10/756/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/188/10/756/F1) Frontispiece from John Charles Bucknill and Daniel Hack Tuke’s *A Manual of Psychological Medicine* (1858), one of the first widely used textbooks on the diagnosis and treatment of insanity. Like other alienists, Bucknill and Tuke believed that madness took different forms and that distinct types of insanity could be read on the countenances of their patients. Image courtesy of Courtesy Wellcome Library, London If the origins of madness lay buried in the recesses of human (un)consciousness, its cure likewise revolved around questions of meaning. It was by making the unconscious conscious and by reconfronting meanings we had fruitlessly sought to repress that we could successfully overcome the demons that lurked within us. Madness was indeed all about meaning. Contemporary psychiatry has a very different view. Where an earlier generation of psychiatrists sought to disentangle and make sense of the disturbed behaviours, emotions and cognitions of their patients, their modern-day counterparts are disposed to dismiss these surface manifestations of mental illness as so much epiphenomenal noise. Madness, they claim, is brain disease *tout court*. Its origins lie in disturbances of the chemical soup that bathes our brain cells, in defects in our hereditary endowment or in some mysterious mix of the two. Breakthroughs in psychopharmacology are sought to repair these underlying somatic lesions and make the mad sane. The symptoms of mental illness are of no enduring significance or interest, save as the surface manifestations of a bodily disease and the visible markers that permit the profession to identify the (very) many who need its interventions. Psychiatric treatments are resolutely directed at defective bodies, not unhinged minds. I am no apologist for Freud or for psychoanalysis, whose intellectual vulnerabilities and therapeutic shortcomings I think are legion. Still, on the question of madness and meaning, I think that generation of psychiatrists was more insightful than the somatic reductionists who currently rule the psychiatric roost. I hasten to make two points to avoid misunderstanding: I have no truck with those who dismiss mental illness as a myth or the social construction of a malevolent psychiatric profession; and I am equally not suggesting that biological factors will turn out to have no role in at least the major forms of mental illness — the sorts of disturbances, for example, that we now call bipolar disorders or the schizophrenias. Quite the contrary, I would be astonished if biology were not part of the picture, although this remains more of a metaphysical wager than established scientific truth. I have no truck with the Szaszians or the sociologists who insist that mental illness is all a matter of labels, let alone the crazy calumnies of the Scientologists. What I do insist, however, is that mental illness remains “the most solitary of afflictions to the people who experience it; but … the most social of maladies to those who observe its effects.”2 ![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/188/10/756/F2.medium.gif) [Figure2](http://www.cmaj.ca/content/188/10/756/F2) *Ward of the Madwomen at St Bonifacio’s Hospital, Florence* (1865), by Telemaco Signorini (1835–1901). St Bonifacio’s Hospital was founded in Florence in 1377, becoming an asylum for the insane in the 18th century under the rule of Grand Duke Piertro Leopoldo I. The departures from the common sense reality most of us imagine we share (and that we collectively call “mental illness”) are thus inextricably bound up with the surrounding culture. Furthermore, the very distinction that biological reductionists seek to make between the realms of the sociocultural and the biological is profoundly misplaced, at odds with what the best neuroscience has to teach us about human nature. Human brains are not immutable organs that we are born with. To the contrary, they are remarkably plastic, and they remain so through our lifespan. Our social and psychological environment continuously influences how our brains develop and function in the most profound ways, such that the social becomes built into, and helps to shape and transform, the biological. Thus, the sociocultural environment cannot be simply dismissed in favour of a presocial biological determinism. Any attempt to disentangle the two and to resort to pure biological determinism is doomed to failure. It rests upon a category mistake. More tellingly still, the neuromaniacs, as one critic has called them,3 are in my view deeply mistaken when they address the problem of human consciousness in mechanistic terms and assert that we humans are simply automatons, nothing more than complicated machines who live fully determined lives along pathways preprogrammed into our bodies and our brains. We are not just somewhat more intelligent chimpanzees. The ways we think, behave and feel are deeply dependent on the extraordinarily complex culture human beings have created over many millennia. That remains the case even when those cognitions, behaviours and emotions are deeply disturbed and profoundly at odds with “normality.” On theoretical grounds, I find biologically reductionist accounts of mental illness deeply unsatisfactory. A broader acquaintance with the place of madness in human culture only serves to amplify the point. As the title of my book makes clear — *Madness in Civilization: a Cultural History of Insanity from the Bible to Freud, and from the Madhouse to Modern Medicine*4 — I have broadened my interests in the history of madness far beyond my original focus on 19th-century England. I have sought to examine the place of madness across millennia, and not just in the West, but also in Islamic societies, in China, in India and in the vast portions of the planet that fell under the sway of Western imperialism. I offer an empirical rebuke to those who would reduce mental illness to no more than a malfunctioning brain. In choosing to call my book *Madness in Civilization*, I was deliberately referencing arguably the most famous book on the history of psychiatry to have appeared in the past three quarters of a century, Michel Foucault’s *Madness and Civilization*.5 Foucault’s book first appeared in English translation in 1964, the version I first read as a graduate student in the late 1960s and one of a handful of books that prompted me to begin my researches in the field. Not long afterward, I read the much longer French original.6 Although reading the full version helped to cement my interest in the field, it also caused me to be skeptical of Foucault’s version of history. Inspecting the evidence revealed in his footnotes and conducting my own research in the archives only added to my doubts. To be sure, Foucault’s work remained provocative and of considerable heuristic value. Although he was far from the first scholar to attack the notion that psychiatry was an unambiguously liberating enterprise — consider, for example the work of Erving Goffman7 and Thomas Szasz,8 which appeared in the same year as Foucault’s book — his was a perspective I found illuminating, up to a point. Foucault’s body of work amounted in many respects to an assault on the Enlightenment and its values, whereas I count myself one of its disciples and defenders. My work is in many respects highly critical of psychiatry, both in its past and in its present incarnations, but I share neither Foucault’s nor Scientology’s dismissal of the whole enterprise. In addition, Foucault appears to dismiss the depredations and the suffering that are indubitably bound up with bedlam madness, a stance I cannot share given my acquaintance with the realities of the graver forms of mental distress. As will become apparent to those who read my book alongside Foucault’s, we also differ sharply in our analyses of the complex links between madness and civilization. If the titles of our two books are superficially similar, the arguments we each advance are very different. Some may chastise me for criticizing Foucault’s handling of how the relationship between madness and civilization is to be unpacked. After all, the title of his original French edition suggests that this was not the task he set for himself. He did not call his book *Folie et civilisation*, but rather *Folie et deraison. Histoire de la folie à l’âge classique*, a title I believe more accurately indicates what he attempted to do. That his work was presented to an English-speaking audience as *Madness and Civilization* was not Foucault’s idea, or even that of the book’s original translator, Richard Howard. The question of the English title’s origin had long been a mystery. Those of his epigones who were willing to speak with me on the matter professed not to know where it had come from, and no one else seemed to be any the wiser. But a few years ago, it occurred to me to ask Howard himself. His response contained two fascinating pieces of information: he had wanted to translate the full text of Foucault’s work and to give it the correct title *Madness and Unreason: the History of Madness in the Age of Reason* [Richard Howard, emeritus professor of poetry, Columbia University: personal communication, 2012]. The publisher baulked. Presumably because it judged a 700-plus-page tome by a then little-known French academic unlikely to sell, it published only a truncated paperback version. The publisher created the new title, *Madness and Civilization*. As a marketing device, that proved to be a stroke of genius. It also ensured that an anglophone audience would assume that the links between madness and civilization were the central point of Foucault’s researches. By contrast, I chose the title *Madness in Civilization* for my book. Rather than seeing madness as something separable from civilization, the prefix “in” reflects my view of madness as inextricably a part of it, sometimes liminal, but sometimes quite central to human experience. Both madness and civilization are complex phenomena. Just how they have been related to one another over the millenia and across vastly different societies is a subject I find fascinating and anything but easy to comprehend. My book attempts to confront those complexities and to provide a tentative analysis of how to make sense of these mysteries. ## Footnotes * *CMAJ* Podcasts: author interview at [https://soundcloud.com/cmajpodcasts/151418-medsoc](https://soundcloud.com/cmajpodcasts/151418-medsoc) * This article has been peer reviewed. ## References 1. Scull A. Museums of madness: the social organization of insanity in nineteenth century England. London (UK): Allen Lane/Penguin Books; 1979. 2. MacDonald M. Mystical bedlam. Cambridge (UK): Cambridge University Press; 1981:1. 3. Tallis R. Aping mankind: neuromania, darwinitis and the misrepresentation of humanity. London (UK): Acumen; 2011. 4. Scull A. Madness in civilization: a cultural history of insanity from the Bible to Freud, and from the madhouse to modern medicine. London (UK): Thames and Hudson; and Princeton (NJ): Princeton University Press; 2015. 5. 1. Howard R Foucault M. Madness and civilization: a history of insanity in the age of reason [translated by Howard R]. New York: Pantheon; 1964. 6. Foucault M. Folie et déraison: histoire de la folie à l’âge classique. Paris: Plon; 1961. 7. Goffman E. Asylums: essays on the social situation of mental patients and other inmates. New York: Doubleday; 1961. 8. Szasz T. The myth of mental illness. New York: Harper and Row; 1961.