Madness in Civilization

Why do societies create categories for unreason? In Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness, Andrew Scull traces two thousand years of efforts to define, explain, and control what Western and global traditions have called madness. He argues that this story is not only medical but deeply moral and cultural: it tells you what societies fear, condemn, and hope for. Across eras—from sacred healing to asylum reform to drug revolutions—Scull shows how explanations of mental disorder mirror changing ideas about the self, authority, and the boundary between normality and deviance.

Scull deliberately uses the old word “madness,” not because it is neutral, but because it reveals how each age negotiated stigma and sympathy. He warns that when you sanitize history by calling everyone “mentally ill,” you erase real cultural differences. Madness was once possession, sin, genius, or prophecy; later it became pathology, chemical imbalance, or neural circuit error. You cannot understand its long history without recognizing those shifting meanings.

From sacred to natural explanations

In ancient and medieval worlds, madness was entangled with the divine. Hebrew prophets like Saul and Nebuchadnezzar showed divine punishment or spirit possession. Greek physicians countered with humoral medicine, explaining melancholia or mania as imbalances of bile. Scull makes you see that both systems coexisted: the physician’s rational account did not erase the priest’s. Instead, the tension between naturalistic and supernatural explanations became a permanent feature of how humans respond to mental suffering.

Outside Europe, parallel traditions developed. Islamic hospitals admitted the insane for both medical and religious treatment; Indian Ayurveda fused body and soul through the doshas; Chinese physicians located spirit disturbance in imbalances of qi. None separated mind cleanly from body. These global frameworks remind you that medical pluralism—scientific, ritual, familial—was the norm, not the exception.

Christian charity and medieval institutions

In Christian Europe, saints, relics, and shrines became therapeutic centers. Pilgrims at Canterbury or Gheel sought miraculous cures. Church exorcism and theatre dramatized moral order through demoniacs. Yet the same culture created early hospitals that blended charity with control. Families, clergy, and civic authorities shared the uneasy task of managing the disturbed—often by containment more than cure. You begin to see the sociological pattern: every era mixes compassion, fear, and the need for order.

Reason, enlightenment and asylum reform

From the Renaissance onward, madness entered art, philosophy, and anatomy. The early modern period celebrated melancholy as genius and gave rise to stage dramas that turned insanity into moral spectacle—Shakespeare’s Lear and Ophelia are archetypes. But by the eighteenth century, physiology and commerce joined the story: private madhouses, the rhetoric of nerves, Mesmer’s magnetism, and Quaker moral treatment together marked the birth of psychiatry. The “mad-business” became a trade, and the asylum became the public emblem of humane reform.

Scull’s central contention is that these transitions were never simple scientific progress. The rise of psychiatry required the Great Confinement: the building of massive asylums, backed by the state, which promised cure but quickly filled with incurables. Out of this apparatus came both the profession of psychiatry and its ethical dilemma—how to treat human beings who cannot consent, yet whose suffering demands response.

Modern fragmentation and contested authority

In the twentieth century, psychiatry swung between biological and psychodynamic poles. Somatic therapies like malaria fevers, insulin shocks, ECT, and lobotomy sought mechanical cures for unmanageable patients—often with tragic results. Psychoanalysis then reinterpreted madness as meaning, offering the talking cure and reshaping Western culture. War trauma introduced the mass politics of psychiatry: shell shock, PTSD, and military screening institutionalized new forms of suffering. Later came the drug revolution—Thorazine, Valium, Prozac—and the diagnostic revolution of the DSM, which redefined illness through checklists. Each wave redrew the boundaries of professional authority and human dignity.

The human cost and enduring questions

By the twenty-first century, asylums have closed and pharmaceutical capitalism dominates. Yet homelessness, prisons, and untreated illness show the limits of deinstitutionalization. Scull’s long arc warns you that psychiatry’s progress is never linear: each reform solves some problems and creates new ones. His ultimate lesson is historical humility. Madness is inseparable from the societies that name it. To understand it, you must confront both sufferers’ pain and the institutions, ideologies, and hopes built around that pain. (In spirit, Scull’s approach echoes Foucault’s Madness and Civilization but grounds it more firmly in archival, medical, and material realities.)

Scull’s global opening chapters teach you to see madness through multiple cosmologies. In antiquity, insanity belonged to gods, spirits, or temperaments. The Hebrew Bible’s Saul tormented by an evil spirit and Nebuchadnezzar grazing like an ox capture the theologic view: divine wrath manifests as mental disorder. At the same time, Greek and Roman physicians proposed a naturalistic alternative: humoral imbalance. Hippocrates denied divine causes for epilepsy and placed madness in the brain’s material disturbance. Melancholia, mania, hysteria—all had bodily explanations, even if the “balance” metaphor proved metaphorical more than empirical.

Parallel worlds of explanation

As you move eastward, you find the same pluralism. Islamic physicians like Avicenna translated and expanded Galen, yet popular healers still invoked jinn. Treatment ranged from opium and baths in Cairo’s bimaristans to Qur’anic exorcism. In India, Ayurvedic texts located derangement in the three doshas, and later Muslim rulers imported Yunani medicine, blending Greek and local systems. China’s tradition, centered on harmony and qi, treated emotional disorder as disturbance of flow rather than singular disease. Each civilization managed mental disturbance through its own moral logic—blending science, spirituality, and family duty.

Key pattern

Across civilizations, madness was always more than illness. It was a moral, cosmological, and social concern that demanded collective justification, not simply medical intervention.

The result, Scull concludes, is that the “medicalization” of madness is a late and Western development. Most human societies lived comfortably with hybrid explanations—disease, sin, and spirit coexisting. Understanding this multiplicity prepares you to see later European developments not as scientific inevitabilities but as political and cultural consolidations.

When Rome fell, responsibility for madness shifted to the Church and the community. Scull emphasizes how medieval Christianity transformed madness into both a spectacle of faith and an instrument of charity. Shrines like Canterbury, Conques, and Gheel became magnets for the suffering, offering ritual healing through relics of saints such as Becket and Dymphna. Miraculous recovery validated divine power; failure reinforced faith’s test.

The social functions of miracle and care

These sites were not only spiritual centers but organizers of local economies, attracting pilgrims and sustaining hospices. At Gheel, the practice of lodging insane pilgrims with peasant families after ritual cleansing created a form of proto‑community care centuries before psychiatry’s invention. Meanwhile, exorcism theatricals and morality plays staged the moral boundaries of sin and reason, turning madness into pedagogy.

Monastic and civic hospitals

As urban life revived, monasteries and later civic hospitals offered limited refuge for those judged dangerous or helpless. They blurred lines between charity, custody, and punishment. Families remained essential caregivers, while violent or disruptive individuals were sometimes chained or sequestered. The medieval blend of mercy and order proved durable; it reappeared later in the asylum’s dual mandate of cure and control.

For Scull, the Middle Ages represent not ignorance but moral imagination: a world that located madness between faith and social responsibility. It created precedents—pilgrimage, confinement, ritual—that later secular systems would transform into institutional therapy.

In the Renaissance and early modern periods, you encounter a profound diversification of ways to think about inner life. Scull shows that melancholy, hysteria, and enthusiasm became cultural obsessions, crossing between art, medicine, and religion. After centuries of collective symbols, madness now took on individuality. Melancholy was both disease and emblem of genius: Dürer’s Melancholia I (1514) made introspective gloom an artistic pose. Robert Burton’s Anatomy of Melancholy cataloged the condition as intellectual disease and divine melancholy alike.

Gender and performance

Scull reminds you that early modern psychiatry expressed deep gender bias. Hysteria, derived from the Greek for womb, explained women’s fits, suffocations, and emotions as wandering uteruses or vapors. It exposed social anxieties about female autonomy even as physicians like Soranus or Bright medicalized old superstitions. Meanwhile, theater turned mental breakdown into literary exploration: Shakespeare’s feigned or real madmen—Hamlet, Lear, Ophelia—became mirrors for conscience and guilt. Madness moved from a moral category to an existential one.

The aesthetic of unreason

Painters and dramatists displayed insanity as withdrawal or fury, associating chains and nakedness with the loss of civility. These representations helped the public imagine madness and normalized its observation. By the eighteenth century, such imagery fed into the founding of madhouses, where watching the insane itself became a social ritual—as in Bedlam’s visitors’ galleries. You begin to sense how spectacle, commerce, and science were already intertwined.

(Parenthetical note: Foucault located this aesthetic shift as the “classical age” separation of reason and unreason; Scull, drawing from archival records, grounds it in economics, urbanization, and growing medical entrepreneurship.) The modern mind, in this view, was born theatrically—half science, half show.

As trade and towns expanded, the question of where to keep the mentally disturbed became urgent. Scull narrates the rise of the madhouse as a business—private, profitable, often grim. In seventeenth‑ and eighteenth‑century Britain and France, urban pressures and family embarrassment fostered private madhouses like Warburton’s or Mason’s, alongside public ones like Bedlam. Treatment ranged from neglect to coercion: chains, whips, water shocks, and Joseph Mason Cox’s “swing.”

The moral treatment revolution

Reformers such as William and Samuel Tuke, Pinel, and the Pussins rebelled against cruelty by advocating traitement moral: kindness, order, work, and persuasion. The York Retreat’s calm domestic setting symbolized the Enlightenment’s belief in environment shaping mind. These approaches influenced France’s and Britain’s asylum reforms of the early 1800s, promising therapeutic confinement for cure. The rhetoric of moral order and benevolence allowed the asylum to multiply—from local refuges to great public edifices like Colney Hatch.

A paradox emerges

What began as humane care evolved into confinement on an industrial scale. The asylum promised cure but institutionalized custody—a pattern that persisted for a century.

Professionalization and science

From these institutions grew psychiatry as a profession. Physicians organized associations, and biological models gained prestige with discoveries like Bayle’s syphilis‑derived general paralysis. Yet therapeutic success remained limited. Overcrowded public hospitals eroded ideals; chronic patients outnumbered curable ones. Scull calls this the “Great Confinement”: an era of optimism turned to bureaucratic stagnation. Still, the asylum system created psychiatry’s social identity—a mix of science, governance, and moral authority.

The same cycle repeated globally: reform turned to control, and ideals to routine. Understanding this history helps you question how easily compassion can morph into coercion when medicine serves social order.

Twentieth‑century psychiatry oscillated between two grand visions: mechanistic cure through the body and interpretive cure through the mind. Scull calls this the century’s defining dialectic. When asylums lost credibility, psychiatrists turned to spectacular physical interventions—the somatic arsenal—seeking proof of medical modernity. Treatments like Wagner‑Jauregg’s malaria therapy, Sakel’s insulin comas, Meduna’s convulsions, Cerletti’s ECT, and Freeman’s lobotomy multiplied despite grave harm. Each was hailed as miracle before ethical reckoning followed.

The moral of overreach

These methods show how institutional power and professional desperation can override evidence. Physicians became engineers testing human brains. Public acclaim—Nobel Prizes for Wagner‑Jauregg and Moniz—masked casualties, mortality, and lifelong disability. Scull insists you view them as both scientific experiments and moral failures born of therapeutic hunger.

Psychoanalysis and the talking cure

Meanwhile, Freud and Breuer opened another frontier: making madness meaningful. Their talking cure turned symptom into symbol. Psychoanalysis offered patients narrative agency, and after Freud’s 1909 American lectures, it conquered U.S. psychiatry. Post‑War America made psychoanalysis a cultural orthodoxy—from Hollywood scripts to university clinics. Scull observes that its rise had as much to do with social prestige as with evidence. By the 1980s, drugs and insurance logic displaced it, but its metaphors—the unconscious, repression, transference—still shape how you speak about the mind.

Together, these twin traditions—somatic and analytic—revealed psychiatry’s unstable foundation: it oscillates between mechanism and meaning, between cure of the brain and interpretation of the soul.

Scull conveys how total war redefined psychiatry’s social mission. World War I’s trenches turned the invisible wounds of fear and shock into national emergencies. Soldiers who could not fight were labeled shell‑shocked; administrators feared contagion of cowardice. Treatments ranged from brutal electric reconditioning by Yealland and Kaufmann to humane talking therapies by W. H. R. Rivers at Craiglockhart, who treated poet Siegfried Sassoon. You see in these contrasts the perpetual moral dilemma: is the mad soldier a patient or a defaulter?

From war neuroses to PTSD

World War II and later conflicts institutionalized psychiatry within the military. Screening, group therapy, and rehabilitation became tools of manpower management. Out of these experiences grew the modern idea of trauma—culminating after Vietnam in the DSM’s addition of Post‑Traumatic Stress Disorder. What began as military pragmatism turned into a major civilian diagnosis reshaping notions of victimhood and moral injury.

The hidden continuity

For Scull, war demonstrates psychiatry’s dependence on context: its categories expand or contract according to state interest. Trauma’s clinical recognition owed as much to veterans’ activism and public empathy as to science. Madness, again, reflected society’s conscience. Understanding PTSD as both discovery and invention helps you appreciate how psychiatry evolves through collective stress rather than laboratory certainty.

From the 1950s onward, psychiatry reinvented itself as a pharmacological enterprise. Chlorpromazine, marketed as Thorazine, calmed psychotic patients and symbolized a therapeutic revolution. Scull shows that this breakthrough merged clinical hope with industrial opportunity. Pharmaceutical giants transformed psychiatry’s public image from custodial to chemical. Antipsychotics, antidepressants, and tranquilizers promised order at scale, but also created dependence, new side effects, and massive profits.

The DSM revolution

To legitimize research and insurance claims, psychiatry needed diagnostic precision. DSM‑III (1980), led by Robert Spitzer, supplied operational checklists that standardized practice. Reliability improved, but at the cost of meaning: surface symptoms replaced personal narratives. Pharmaceutical trials now fit easily into DSM boxes, fueling drug approvals and expanding disease categories. By the 1990s, unprecedented diagnosis rates for ADHD, bipolar disorder, and depression revealed the economic logic behind medicalization.

Medicalization and skepticism

Scull doesn’t deny symptom relief but warns that psychiatry’s alliance with market incentives reshapes reality itself. When suffering is codified for reimbursement, ordinary unhappiness becomes pathology. Critics like Allen Frances and the NIMH’s Thomas Insel agree that reliability without biological validity yields shallow science. Thus, the age of drugs and DSM brought order—and subtle distortion. Madness became a commodity, quantified and billable.

To understand the twentieth century’s darkest turn, Scull confronts psychiatry’s complicity with eugenics. Beginning with Galton’s theories and Maudsley’s fears of hereditary degeneracy, Western nations promoted sterilization of the “unfit.” By 1940, dozens of U.S. states had such laws, endorsed by Justice Holmes’s infamous phrase: “Three generations of imbeciles are enough.” These precedents inspired Nazi Germany’s sterilization and euthanasia policies. Under the T‑4 program, psychiatrists supervised the killing of tens of thousands in clinics like Hadamar—prototypes of later extermination camps.

The ethical reckoning

Scull insists you see these events not as aberrations but as warnings: when medicine allies with state ideology, healing turns lethal. After 1945, revelations of atrocities discredited eugenics and forced psychiatry to rebuild legitimacy through humanitarian reform and empirical science. Yet the same institutions soon pursued new forms of control—lobotomy, chemical sedation, mass hospitalization—suggesting that the impulse to manage deviance survived moral collapse.

(Context note: This chapter echoes themes from Medical Nemesis and Hannah Arendt’s analyses of bureaucratic evil, translating them into psychiatric history. The central question—what happens when doctors become agents of policy—remains urgent.)

Scull ends with the aftermath of the asylum’s demise. Beginning in the 1950s, governments touted “community care” as humane modernization. Drugs like Thorazine helped stabilize some patients, but the deeper motivations were economic and political: closing hospitals shifted costs from states to families and cities. In Italy, Franco Basaglia’s Law 180 (1978) outlawed traditional asylums, while the U.S. and Britain pursued mass discharges under fiscal pressures.

The promise versus the reality

You learn that deinstitutionalization succeeded for those with social support but failed catastrophically for the poor, isolated, and chronically ill. Many ended up homeless or incarcerated—Los Angeles County Jail and Rikers Island now contain vast psychiatric populations. Boarding houses and nursing homes replaced locked wards but not meaningful care. The “sidewalk psychotic,” Scull writes, is deinstitutionalization’s visible monument.

Lesson for policy

Closing institutions without funding alternatives transfers suffering, not responsibility. Community care requires real communities, not bureaucratic slogans.

Ending where he began, Scull invites you to look beyond psychiatry’s technical debates to its human stakes. The management of madness is a test of civilization’s compassion. Every reform—ancient or modern—reveals how societies balance fear, empathy, and control. That tension, he insists, will never disappear.