Two new scholarly works, both with ambitions to provide a full historical account of ‘madness’ – from the ancient world to the late twentieth century – appeared in 2015. Both authors argue that ‘madness’ is a term that is far more encompassing than mental illness, and one more historically accurate than, for example, ‘insanity’ over the longer term. Madness is witnessed, glimpsed and observed in both books on a large canvas and in myriad ways. Perhaps because of their scope, both histories tend to fall into a received pattern of inquiry, with the narrative trajectories of the two books being very similar in their story arc: from accounts of madness and lunacy before the ‘great confinement’, the era of the asylum and madhouse, through to the modern age of medicine and institutions; and, later, wartime environments for medical experimentation, post-war medicine and mental illness, right through to critical accounts of the Diagnostic and Statistical Manual (DSM) and the pharmacological revolution. Ultimately, these books and their authors place the history of madness and mental illness and its treatments firmly inside a ‘medical history’ literature. And yet the major contribution of these texts lies in their sociocultural analyses of ‘madness’. What was madness, in medicine and in cultures, is the major theme addressed by both Pietikainen and Scull.
If histories are always produced from the present, as Foucault argued, then the worry we have over mental illness in our own times certainly informs the production of these histories. We are now seeing an array of aspects of this Western society crisis: with rising rates of mental illness; the increased visibility of ‘madness’ in public due to homelessness and addiction; anxiety over medical treatments and the efficacy of mental health public policy; debates about the efficacy of drug regimes; and issues of advocacy for ‘service users’ or those with lived experiences of mental illness. Some of these topics inform Scull and Pietikainen. These are both intellectually mature scholars whose insights into the wretched psychiatric experiments of the twentieth century offer us new ways to assess and to understand the multiple and intertwined histories of psychiatry in our present moment. But are these actually histories of madness? Or are they histories of the changing human responses to mental disorder and experiences of madness over time? There is a subtle but vital difference.
Not since the 1960s and 1970s have we seen such large-scale accounts of the history of mental illness and society, or madness and civilisation, as Pietikainen remarks, writing himself into this now significant scholarly oeuvre. When he wrote, Michel Foucault sought to map and position the field: to assert a set of meanings about institutions of confinement and power relations in history. Scull purposefully references Foucault in his book’s title, suggesting that he acknowledges not only a intellectual lineage, but also promises a rethinking of the question of madness inside civilisation. Later, psychiatric historian Edward Shorter wanted to write about a field transformed by biomedicine in the middle of the twentieth century.Footnote 1 This was a different project, but Shorter, too, was influenced by the critical social inquiry of the 1960s and later.
Scull’s career engagement with the field is deeper. From his earliest studies of Victorian lunacy reform through to his later works of the 1970s and early 1980s, focused on the social histories and social organisation of madness and derived, in part, from his background as a sociologist, Scull has been aware of his role as a critical voice in madness studies.Footnote 2 Of a different generation of scholars, Pietikainen explicitly pays homage to historian Roy Porter, for example, in his Introduction’s emphasis on ‘the patient’s voice’ and by the idea that his book is a ‘human-centred’ history (4). His engagement with Scull’s work is relatively limited.
Whatever their generational differences, both authors reviewed here are equally concerned with this problem of madness and the human condition, wrought most eloquently by Scull both through his words and through the many images illustrating his book – images designed to be reminders of the deep fascination with the problem of madness in historical and cultural periods. The concept of madness with which both authors operate is that it has been present in societies and cultures for a long time, not only realised with or identified by the asylum, or ‘socially constructed’, as Scull suggests, but actually evident and present in everyday life. Scull insists that madness is not always inside ‘the medical grasp’ (15). This concept of madness allows both histories to witness change over time, to notice and identify it in a range of contexts. Yet it also suggests that madness might be understood as a special phenomenon outside the medical frames that have developed around it and the models to treat it. Treatments, then, potentially become the subject of historical specificity, rather than madness itself, an idea that might trouble some historians, although some reflection about the danger of retrospective diagnoses appears in both texts.
There is a significant overlap between these two books. This might be inevitable, given that both authors plot a history using existing sources and make a synthesis of what is known and understood about madness. Yet the differences in tone and argument between the two works reveal also some of the deeper and current tensions in the field of the history of mental illness and psychiatry, as hinted above. Where Pietikainen claims ground as an author integrating the ‘voices’ of the mentally ill inside the history he writes, Scull’s assertion of his own mission is that he locates the cultural moments during which we might hope to gain access to the meanings of madness. Scull takes as his specific departure point the idea that ‘madness has much broader salience for the social order and the cultures we form part of’ (14), an idea that has great resonance in forms of art, music and religious expression. Furthermore, it allows Scull to comfortably embrace a long sweep of historical time. Pietikainen’s focus might reasonably be said to be much more of a historical account of the twentieth century, given that half of the book is devoted to that era going into the present, in a work divided into four sections.
These tensions are productive. The field of the history of psychiatry might be said to have embraced a broad array of ways to imagine madness and mental illness in the past, including those viewed through and by the medical lenses of practitioners, institutions and scientific experimentation, and also by other ways of seeing, such as histories of madness, families, extra-institutional care, early modern and emerging eighteenth-century models for health care, and so on. Medicine itself as a ‘field’ of knowledge and practice embodies some of these concepts and so the histories of madness and institutions have always fallen into the wider description of histories of medicine too.
So what are the gems for the historian of medicine and psychiatry in these books? In the ancient world, the sources for the history of madness include biblical and other literary texts, storytelling, ‘physick’ in the Greek and Roman worlds, as well as visual depictions of health and illness. Finding madness in the Eastern and Islamic worlds is fruitful for Scull, who weaves Eastern world evidence together with the worlds of Christian Europe and spiritual solutions to illness and healing, although the interpretation might reflect our present sense of ancient world motivations. The very role of storytelling in this early history of madness is important, with medieval culture being a useful moment for the assessment of the role of imagining madness through performance and textual renditions of the horror of a mind lost. Although madness (and medicine in general) are often cast from western European perspectives, with the Asian world still largely separate, these books aim to draw in aspects of the non-Western world, although in fairly limited ways.
In both of these works, the asylum as an institution is accorded a huge significance, both in terms of the historical impact of the institution and the way in which institutions overshadow the story in terms of sheer pages devoted to the ‘Great Confinement’. As a historian who has spent most of her time examining nineteenth- and twentieth-century institutional records, I am always interested to see how historians understand and reveal the place of institutions in historical narratives of madness. Scull’s chapters on these institutions begin with his focus on the madhouses and their doctors, drawing on his own rich work in this field, as well as the deep inquiry which is a hallmark of the scholarly terrain over the past few decades. The argument that, from the seventeenth century, in parts of Europe, the idle, poor, incapacitated and mad were swept up in the beginnings of a new wave of institutional confinement is an idea reasserted here to show the longer historical antecedents of social institutions which aimed to ‘shut people up’ (133), a set of practices which Scull links to the trades around managing people in life and death – trades which serve to underline the new emerging economic order.
It was this order, suggests Scull, that produced the kinds of disorders which came to boost the asylum’s role in everyday life as a solution, a place to deal with nerves and nervousness or more desperate illnesses; an ordering institution for families, communities and the mad themselves. Scull’s history investigates these practices of institutional isolation as revealing of sophisticated and insidious theories of social and population degeneration (244). Degeneration tended to cement the meaning of the institution for the late nineteenth century as a clinic of the weak and ‘other’ peoples who crowded social institutions of the period. Pietikainen, who begins this phase of his own book with a chapter on ‘The Age of the Asylum’, asserts these same ideas, using some of the same examples. Like Scull, he then moves into a discussion about the way in which the institutions created medical models for the treatment of madness. In Ireland, argues Pietikainen (drawing on the work of Elizabeth Malcolm), although families came to rely on the asylum, their use of it was, in part, the result of the social anxieties created for families in a punitive colonial state and a strong association between criminality and mental illness (154–5).
Pietikainen hints at a major question shaping asylum studies and the prominence of the institution in both of these books points to another aspect of our present thinking. How might we explain the great reach and uptake of these institutions? Mark Finnane cogently explained the efficacy of the institution in his early work.Footnote 3 More recently, I argue that social institutions – including medical and welfare institutions – should be viewed as far more central to national and global history writing.Footnote 4 Instead of relegating these examples to social histories of illness or poverty, or madness, should we instead view these social institutions, which housed so many peoples across so many places, as being deeply implicated in histories of mobility, migration, pathways and patterns of life, especially in the age of imperialism and empire? Certainly, this argument is borne out by the work of both Scull and Pietikainen, who weave imperial world and colonial examples into their global studies, also suggesting that the literature about British Empire, French Empire and other European imperial practices is large and important enough to be seen as a structural effect of the dispersal of knowledge and practice in psychiatry and its institutions.
Both works of history offer some new ideas. Pietikainen’s chapters ‘Living and Dying in Asylumland’ and ‘Naming the Mad Mind’ bring fresh perspectives and interpretations of the role and impact of institutions across places before the twentieth century, particularly through empirical examples from Finland and other European countries. The way in which Pietikainen reinterprets Erving Goffman’s thesis about the ‘total institution’ in the light of his interest in the twentieth century era places his work as a more powerful account of the problem of madness itself. Here, he wrestles with the way that patients themselves were progressively silenced (145) and the persistence and intensification of institutional regimes of power, control, repression and violence. The discussion about naming mental diseases, diagnoses and classification allows Pietikainen to draw links between ancient world descriptions of madness and those reaching into our present. Scull offers some powerful new insights and ways of understanding the hospital for the insane through its eventual demise, in chapters concerned with avoiding the asylum and the move towards deinstitutionalisation. Both authors therefore assert that different meanings were brought to madness through people concerned with questioning the power and relevance of the asylum in the twentieth century.
To get closer to madness as the subject, there are intriguing examples in Pietikainen’s Madness: A History in which he explains delusions, such as ‘fragile glass people’, or glass delusions (64). This delusion – historically specific, but with twentieth-century manifestations – reminds us of the value of describing and understanding delusions as evidence of time, space and cultural moments. Likewise, specific diagnoses or labels of madness, or ‘maladies of the mind’, might be bizarre, such as ‘wolf-madness’ or lycantrophy (a rare form of melancholic disorder), but they are also reminders of the past meanings attached to behaviours; reminders of the culture and time-bound madness we no longer see. Reading about these I was unsure about whether they stand for much more than a passing interest on the part of the author – a nod at curious phenomena. But Scull also delves into the role of the delusion as artefact. Recorded delusions, whether clinically documented or written about and represented in other forms, become traces of madness, which, as Foucault remarks, are the only things left of madness itself as time passes.
There is another question we can ask of these histories. How far do they entertain questions about what might have been? For example, was institutional confinement inevitable after all, or was it simply a practice born out of specific historical, cultural and economic conditions in the western world? Although institutional solutions in Europe were widespread, the case of what we would now term out-of-home community-based care was a feature of Belgium’s town Gheel from the fourteenth century. In Japan, as scholars show, other solutions were provided in law for home-based confinement, governed by rules about home carceral environments. Neither work dwells much on this speculative historical space.
By interpreting their understanding of science and experimentation and the desperate remedies’ of the twentieth century and also wartime – madness itself – readers might get closer to appreciating the political stance in both works. Likewise, there are useful insights into the pharmacological ‘revolution’ of the latter part of the twentieth century, the impact of the DSM and the closure of institutions. Scull’s ‘A Psychiatric Revolution?’ is an excellent chapter. It pulls together the philosophical ‘end’ to the age of the total institution and the practical outcomes of this policy which swept the Western world. Interesting anomalies, such as the increased institutional confinement of the mentally ill in Japan in the twentieth century, explicable through the urbanisation of mobile Japanese workers, as argued by Akihito Suzuki, remind us of the inherent difficulties of the presence of mental illness in societyFootnote 5 . Scull brings the various elements of the problem into historical conversation: closure, rising numbers of the mentally ill, the pharmaceutical revolution and the ‘reconstitution’ of psychiatry.
Madness in Civilization is an impressive, mature and fluent book. It is a powerful work of cultural history and it contains much evidence from literature, art, film, music, physicians’ writing and reflection, medical writing and more. Madness: A History is an uneven work which covers enormous scholarly territory. Parts of the argument are based heavily on those of others, such as the sections relating to colonial psychiatry, indicating that Pietikainen had a daunting task of arranging, reassembling and arguing for aspects of the larger story. While not so much a criticism as a recognition that such broad histories must, inevitably, become difficult to produce on the basis of ‘original’ research, I wondered if limiting the scope and focus of the work to an account of the twentieth century might have had real strength of purpose, allowing Pietikainen’s strengths in writing contemporary history to shine and also profiling his intention to include the voices of the ‘mad’, a task arguably made more meaningful when captured inside a specific and shorter time period, as his later chapters suggest. The many examples of lived experience in this book bring it closer to a history of madness and its treatment from the multiple points of view of the mad themselves. The ‘mad’ in Scull’s book tend to be celebrated examples.
When understood as more than chapters and arguments, but also as objects, these works tell us something more about madness: in particular, Scull’s hardback book is a very handsome and beautifully illustrated tome, with such potent images that it has another layer of interpretive power, simply because the visual illustrations tell us much more again about these lingering marks of madness in the past. Pietikainen provides useful bibliographies at the end of each chapter.
To stand apart, works of historical synthesis should perhaps also make arguments, present evidence from new angles and question established ideas about historical narratives. In small ways, both authors do this, finding areas inside their books where innovative and perceptive accounts of the past might shine new light. As readers and critics, in an age of information saturation, there is possibly some comfort in knowing that these works of historical synthesis and interpretation tell a familiar tale of our collective understandings of madness, making it possible for historians to understand its manifestations over time. The final assessment of ‘madness’ we might reasonably take from both authors is, though, a complex one: while these books suggest that madness historically existed independently of the institutions created to confine it, both also concur that the institution of the asylum itself produced madness.
My final assessment of these works must reflect on how we should expect these books to have an impact on their fields of inquiry. Read together, these works make a timely intervention. The books will act as authoritative accounts, overarching narratives of mental illness historically construed. Scull’s will make a greater impact on cultural history and in the field of the history of mental health, given his stature. In part, due to his inclusion of European case studies, which act to amplify the larger world narrative, Pietikainen’s work will introduce a new generation of European and international scholars to the social and cultural problem of madness and its treatments over time in diverse societies and places.
