Madness and Civilization: A History of Insanity in the Age of Reason

l’Hôpital Général de Paris was an institution founded by Louis XIV in 1656 for the purposes of confining the poor and “mad.” In Madness, Foucault ascribes great meaning to the moment of the hospital’s foundation, using it to mark the beginning of an era that conflated medical treatment of “madness” with its corporal punishment. This era, in his estimation, ended in 1794 when Phillippe Pinel broke the chains used to restrain “mad” inmates. l’Hôpital Général thus becomes the token Enlightenment “hospital” within the book, a stand-in for all such institutions, which were scattered throughout Western Europe during the period. Other institutions addressed in Madness include Bicêtre Hospital, and the Salpêtrière (both of which still operate as hospitals today). Bicêtre is notable for being the location of Pinel’s aforementioned chain-breaking.

The cruel practices of these hospitals are a key area of focus for Foucault, addressing the broader theme of Medical Treatments as Institutional Policing of “Madness.” For example, he describes how basement level cells at Salpêtrière, which would be flooded sewage every time the Seine’s water levels rose, were reserved for the most severe cases of “madness” in patients: “When practices reach this degree of violent intensity,” Foucault asserts, “it becomes clear that they are no longer inspired by the desire to punish nor the duty to correct” (81). Cruelty as a method of dehumanization and control is the model Foucault uses to understand the inhumane policies of these institutions, and a motivation he subsequently assigns to Enlightenment society as a whole.

François Boissier de Sauvages de Lacroix (1706-1767), referred to commonly as Sauvages, was a French botanist and physician who was born in Alès and studied at the University of Montpellier. His major contributions to the field of medical science were concerned with nosology, the classification of diseases. For Foucault, this process of classification, which Sauvages’ work emblemizes, is central to the Classical Period’s relationship to “madness.” Other thinkers that Foucault cites as being involved in this project of classification include Alexander Crichton (1763-1856), Thomas Sydenham (1624-1689), and Robert James (1703-1776), as well as many others. Sauvages’s particular nosological theory was based on the idea that the body and soul responded to fear in a variety of ways that corresponded to a variety of “madnesses.”

William Tuke (1732-1822) and Phillippe Pinel (1745-1826) were two key reformers of the psychiatric treatment system. In Madness, Foucault treats them as inventors of the modern asylum. However, many medical historians understand institutions, like l’Hôpital Général, that had been imprisoning the mentally ill long before Pinel and Tuke’s reforms to have also been asylums. Although both men revolutionized the medical industry’s attitudes towards “madness,” pushing for more humane treatment conditions, Foucault is careful to highlight the ways in which they perpetuated power structures that oppressed the mentally ill. The humane treatment that they offered, Foucault posits, was predicated on the threat of a return to the medical abuses of the past. He reports, for example, that at Tuke’s Retreat, caretakers threatened that “if [a patient] did not control himself, it would be necessary to go back to the old ways” (254). While Tuke and Pinel represent a form of social progress in Foucault’s eyes, their shortcomings are also a central focus of his analysis.

Phillippe Pinel was born in the French commune Jonquières, and studied medicine at the Universities of Toulouse and Montpellier. In the years leading up to the French Revolution, the restrictive bureaucracy of the ancien régime prevented him from practicing in Paris as he desired. When the Revolution began, he sympathized with the rebel cause, and befriended influential revolutionaries through his connection to Madame Helvétius, who ran one of the most notable salons in Paris. 

After the establishment of the First Republic, Pinel was made Physician of the Infirmeries at Bicêtre Hospital, and later Chief Physician at the Hospice de la Salpêtrière, both of which housed hundreds of those who had previously been deemed “mad” by the French state. Upon attaining these positions, Pinel set about reforming the hospitals’ treatment of the mentally ill, and began by ending the use of shackles to restrain inpatients; Foucault cites a popular legend of Pinel personally removing the chains at Bicêtre, when this was in fact done by his colleague Jean-Baptise Pussin. Other key reforms made by Pinel include ending the practice of bleeding, purging, and blistering patients, and replacing these methods with observation and conversation-based treatment.

William Tuke was born in York, England to a Quaker family. In 1791, he was inspired by the case of Hannah Mills, a widow who had died in the care of the York Lunatic Asylum, to found the York Retreat. He envisioned the Retreat as a space where “moral treatment” would be administered to the mentally ill. Foucault places heavy emphasis on how Tuke’s religious values informed his conception of “moral treatment,” writing, “Let us not forget that we are in a Quaker world where God blesses men in the signs of their prosperity. Work comes first in ‘moral treatment’ as practiced at the Retreat. […] Through work, man returns to the order of God’s commandments” (255). This religious moralist underpinning of Tuke’s humane reforms is in contrast to Pinel’s, which Foucault asserts was primarily concerned with establishing a morality based in the secular thought of the French Revolution.