A landmark topical study from Foucault’s early career, History of Madness took nearly forty years before arriving in the U.S. in a full translation. Jean Khalfa’s  magnificent treatment of the sprawling text delivers Anglophone readers more than just extra pages. The differences between Madness and Civilization (based on the 1964 adaptation) and History of Madness (based on the original 1961 version) extend to conceptual nuances as well. In particular, the abridgment of the critique of psychiatry, in Madness and Civilization, flirts with a characterization of madness as repressed genius. But the more detailed argumentation in History of Madness, especially its focus on the institutional disciplines surrounding reason, emphasizes a conscientiously empirical archaeology of reason instead. Still, a central lament, for the loss of unreason after the 18th century, remains in force across both texts.

The lament unfolds across conceptual terrain. Rationality and reason, as key terms, are understood by way of their reflection or consummation in unreason and madness. Splits and inversions abound to bound these contradictions. Foucault studies these discursive objects through their negations. A reader who searches for essential or natural positions will often find frustration due to the same twists and reversals. Ideas of nature, reason, and truth come under scrutiny throughout the work. Madness is thought here as a function of social and historical conditions, not as an abiding characteristic of human nature.

For that matter, modern medicine, especially psychiatry, confronts an extension of the same critique. So psychiatric medicine cannot hear the voice of the mad or of unreason, and the text is framed as a history of a silence. When the Classical episteme silences madness, though, madness takes on the qualities of an origin, something recoverable. The treatment of the Ship of Fools early on in the text showcases these contradictions. Madness is named and exiled, structured into a vessel’s crew and also set into wilderness, become identifiable but silenced by that identification. Vexingly, even the most passionate invocation of unreason’s voice can lose itself when it attempts to circumscribe the condition of madness without the body of the madman as its own vessel.

The magisterial tome proceeds in argumentative loops, perhaps in echo of Descarte’s voided circles (though we can leave that critique to Derrida). It strives to evaluate the discourse that structures madness withoutr facile relativism, instead concentrating on unreason’s concomitant cultural, economic, social, and political conditions. So, practices of confinement in the  Renaissance and Classical epistemes correlate to fear, especially of liberty. Unreason does not exist unchanged between those epochs, nor does it consist simply in the negation of rationality, but in bedazzlement, in awe – when reason is struck dumb, it reaches its limits. Madness is one such limit, but so is aesthetic tragedy. Instead of engaging catharsis, though, pyschiatry applies morality, the terms of religion rather than art.

Psychoanalysis through Freud, in Foucault’s estimation, changes the course of the doctor-patient relationship, by eliminating that moral judgment. While positivism aligns with liberty, and changes conditions of confinement to reflect physical looseness but conscience’s cages, madness also migrates, to invest in the world around the body of the mad. At the birth of the asylum, madness marks not prisoners but children. Familial elements thereby take precedence in social relations of madness: patriarchal caretaking becomes the practice by which institutions control the mad. Tuke’s retreat gives way to Pinel’s asylum, but the asylum yields to Freud’s couch. Older paradigms, of course, do not disappear, but their utility and valence are recast in light of emergent conditions. The doctor takes on the responsibilities and roles of judge and of father. But modern medicine reaches its limits, in its freeing of madness from physical constraints only to replace them with moral constraints. The turn to art in order to engage with unreason remains beyond medicine’s grasp by the onset of modernity. Citing Goya, Nietzsche, Artaud, and de Sade, Foucault evinces a concluding paradox. Madness both creates and destroys art. The absence of the work of art (oeuvre and labor side by side) might indicate how deeply unreason structures discourse.

Issues of bodies, labor, and aesthetics, in connection with both history and madness, mark a certain impasse. We can neither test nor interpret the logic of lament. What we now call mental illness, or a host of other names linked more to disease than to history, we continue to misdiagnose, falsify, and mistreat on the same bases as did psychiatric moralists in this text. Broader conditions of real existence are dismissed as incidental to medicine. Art’s contributions to the debates reach us as nearly exclusively as advertisements for pharmaceuticals. Unreason undergirds our increasingly technical imaginations, as machines think more for us. The consequences of these shifts may take another hundred years, and another seven-hundred-page dissertation, to unravel.