Chapter 1
When Reason Flees: The Enigma of Madness Throughout Time
Madness haunts humanity in a way few other conditions do. It represents the antithesis of what we consider uniquely human-our capacity for reason and self-control. Yet paradoxically, mental disturbance isn't merely civilization's opposite but an integral part of it, a shadow that has followed human society since our earliest records. Andrew Scull's "Madness in Civilization" has been praised by The New York Times as "ambitious and accessible," while The Guardian called it "a humane and thoughtful book." The work represents the culmination of Scull's forty-year career studying the history of mental illness, drawing praise from both academic and general audiences for its sweeping examination of how societies have understood and responded to psychological suffering. What makes this exploration particularly relevant today is how it illuminates our ongoing struggles with mental health treatment, stigma, and the fundamental question of what constitutes "normal" human behavior in an increasingly complex world.
Chapter 2
The Ancient Dance Between Divine and Natural Explanations
The history of madness begins with supernatural explanations. In ancient societies, mental disturbance was often interpreted as divine punishment or possession by malevolent forces. The Hebrew Bible vividly illustrates this through King Saul, who, after disobeying God's command to utterly destroy the Amalekites, was tormented by an evil spirit that caused dramatic mood swings, pathological suspicion, and episodic violence. Saul's condition-characterized by raving, depression, and homicidal impulses-was temporarily soothed by David's harp playing, though this charm wasn't always effective.
The line between divine inspiration and madness was particularly blurred in prophetic traditions. Biblical figures like Isaiah, Jeremiah, and Ezekiel exhibited behaviors that might appear psychotic to modern observers-hallucinations, trances, and frenzied episodes they attributed to God's spirit. Their contemporaries faced genuine uncertainty: in a world where God spoke through human vessels, those exhibiting signs of insanity might instead be divinely inspired.
Similarly, the ancient Greeks attributed mental suffering to divine intervention. Their literature teems with examples, from Homer's epics to the great tragedies. In the Odyssey, Athena drives Penelope's suitors mad during a feast-they "laughed with jaws not their own" while eating bloody meat. Greek tragedy explored a richer psychological landscape while maintaining supernatural elements. Euripides portrays Heracles, driven mad by Hera, slaughtering his own children while believing they were his enemy's offspring.
Yet alongside these supernatural explanations emerged naturalistic approaches. The Hippocratics firmly rejected divine explanations of epilepsy and madness, mocking those who attributed seizures to divine intervention as "mages, purifiers, and quacks" who merely concealed their ignorance. Instead, they insisted on the brain as the center of emotions and mental activity: "Men ought to know that from nothing else but the brain come joys, delights, laughter and sports and sorrows, griefs, despondency and lamentations." They proposed that madness resulted from humoral imbalances affecting the brain-excessive blood caused nightmares and terrors; phlegm produced quiet mania; bile created shouting, restless madness.
This tension between supernatural and natural explanations would persist throughout history. Even as medicine advanced, religious interpretations remained powerful, with desperate sufferers often trying both approaches simultaneously. The term "melancholy" itself derives from Greek words for black (melan) and bile (chole), reflecting how deeply humoral theory influenced Western understanding of mental states for centuries to come.
Chapter 3
Medieval Minds: Saints, Demons, and the Return of Classical Knowledge
After Rome's collapse, much of the Classical medical tradition was lost to Western Europe. Christianity gained power through miraculous demonstrations-smashing pagan shrines, exorcising demons, and healing the sick. Conversion often followed these displays of divine power, as missionaries convinced barbarians that the Christian God was superior through dramatic demonstrations.
By the sixth century, saints' graves became central to the Church's power. Remains were often exhumed, divided, and distributed to multiple sites to maximize their miraculous reach. The Benedictine monastery at Abingdon amassed an impressive collection including "relics of Christ, pieces of six apostles, bits of thirty-one martyrs" and more. Throughout the Middle Ages, the sick, crippled, and mad sought cures at these shrines, often after exhausting folk remedies and medical treatments.
Medieval culture's portrayal of madness appeared in dramatic works where figures like Herod embodied the blasphemous, mad sinner punished by God. In Dante's Divine Comedy, madness appears as divine punishment, with falsifiers and liars condemned to madness in the eighth circle of hell. Medieval writers consistently portrayed madness as the consequence of sin, while simultaneously viewing sin itself as madness-to violate God's laws meant risking eternal damnation that only a madman would invite.
Yet from the eleventh century onward, an alternative approach to madness emerged through the revival of pre-Christian traditions. As Europe stabilized and grew more prosperous, encounters with Arabic-speaking cultures through the Reconquista and Crusades led to the re-importation of Greek medicine via Muslim physicians like Avicenna. Universities arose, medical guilds formed, and Classical texts were translated into Latin. The invention of printing spread these medical texts widely-Avicenna's Canon of Medicine was printed in 1473 and went through sixteen editions by 1500.
Islamic hospitals influenced European institutions, with some specializing in managing the mad, like Bethlehem Hospital (Bedlam) in London, which gradually evolved from a general hospital to focus on the insane. Though physicians applied humoral medicine to madness, viewing it naturalistically, they prudently acknowledged cases of possession, sometimes deferring to clerical interpretations. Most mad people remained in their communities, with institutional confinement being the exception rather than the rule.
Chapter 4
Renaissance Melancholy: From Affliction to Fashion
The early modern period witnessed dramatic transformations across Europe: the Renaissance revival of Classical learning, the Protestant Reformation, the spread of print culture, and paradoxically, widespread witch-hunts. While Enlightenment thinkers later dismissed witchcraft as superstition, contemporaries firmly believed in Satan's active presence. Both educated and uneducated accepted spirits and ghosts as real, with theological disputes focusing not on their existence but on boundaries between natural and supernatural phenomena.
The sixteenth and seventeenth centuries also witnessed an intellectual vogue for melancholia. Physicians like Andrew Boorde described melancholics as perpetually fearful, dreading disaster, and fleeing from place to place. The condition had diverse origins-some cases arose from brain defects, others from systemic disorders or disturbances in the spleen and liver ("Hypochondriake disease"). Melancholy's symptoms included troubled imagination, corrupted reason, fear, sadness, desperation, and tears without apparent cause.
Though considered "rebellious, long and very hard to cure," treatment involved diet, exercise, fresh air, warm baths, music, and traditional medical interventions like bleeding and purging to restore humoral balance. Paradoxically, melancholia became fashionable among the cultivated classes, with Aristotelian tradition linking it to genius and creativity-a connection famously explored in Robert Burton's exhaustive "The Anatomy of Melancholy" (1621), which counseled the melancholic to "Be not solitary, be not idle."
The boundaries between medical and divine explanations remained blurred, though religious politics ironically contributed to increasingly secular perspectives on madness. Anglican critics dismissed both Catholic and Puritan exorcisms as elaborate "impostures" and "tragicall comedies." This skepticism influenced Shakespeare, who borrowed directly from these accounts when creating Edgar's feigned madness in King Lear. While Edgar pretends demonic possession, Lear's madness is portrayed as natural and human in origin, emerging gradually from psychological onslaughts: betrayal by his daughters, realization of his foolishness, and Cordelia's death.
Madness was a recurring theme in Shakespeare's plays and those of his contemporaries. Shakespeare employed this dramatic device more effectively than his predecessors, presenting richer observations about madness and human nature during a time when the problem of madness preoccupied writers and artists to an unprecedented extent. As Elizabethan and Jacobean drama evolved, madness became part of the dramatist's stock-in-trade, expanding beyond just frenzied characters to include a broader range of mad creatures serving as entertainment, comedy, or plot devices.
Chapter 5
The Birth of the Asylum: Confinement and "Moral Treatment"
By the late 17th century, asylums began advertising their presence in striking ways. In London, Bedlam's grand new building featured Caius Gabriel Cibber's enormous sculptures of melancholy and raving madness. The mad, traditionally viewed as part of the broader dependent poor, began receiving specialized attention as institutions proliferated across Europe. Despite Michel Foucault's claims of a "Great Confinement," most mad people remained with families, sometimes chained in attics or cellars. The wealthy increasingly turned to private madhouses, while lettres de cachet in France allowed indefinite detention without legal recourse.
As eighteenth-century society commercialized life's unpleasantries, the "trade in lunacy" emerged to handle the disturbed relatives of respectable families. Madhouses provided a mechanism for removing the severely mentally ill from public view, sparing families from shame and social stigma. These unregulated establishments prioritized security and isolation, with high walls, barred windows, and often chains to manage unruly inmates.
Writers of fiction seized upon the dramatic possibilities madhouses presented. Tobias Smollett's "The Life and Adventures of Sir Launcelot Greaves" featured a hero wrongfully confined in a madhouse, while Eliza Haywood's popular "The Distress'd Orphan, or Love in a Mad-house" (1726) established a template that would be recycled throughout the century: the virtuous heroine falsely imprisoned in a madhouse by scheming relatives after her fortune, surrounded by horrifying sights and sounds of madness, until rescued by her lover.
The overthrow of Reason was widely viewed as unleashing appetites and passions in their full fury. For those treating the mad, this ontological descent below humanity justified harsh discipline. Thomas Willis, pioneer of brain anatomy, insisted that madmen required "threatenings, bonds, or strokes as well as Physick" and that "furious Mad-men are sooner and more certainly cured by punishments and hard usage, in a strait-room, than by Physick, or Medicines."
New machinery was invented to shock patients back to reality. Joseph Guislain's "Chinese Temple" in Ghent featured a movable iron cage that plunged patients underwater before raising them again. Benjamin Rush created "The Tranquillizer" for the Pennsylvania Hospital, a chair that "binds and confines every part of the body" to reduce blood flow to the brain. Despite initial popularity across Europe and America, these devices fell out of favor by the 1820s as public and professional opinion shifted dramatically against what had once seemed logical interventions.
While some managed the mad through fear and intimidation, others discovered a more nuanced approach. These practitioners saw their charges not as creatures but as fellow creatures who retained some measure of reason. They found that the mad, treated skillfully, could be induced to curb their madness and resume a semblance of normal life. This "moral treatment" emerged independently across Europe and North America, coinciding with Enlightenment questioning of immutable human nature. William Tuke and Philippe Pinel became most associated with this approach, though Pinel's famous "unchaining of the insane" was largely mythical. This new humane therapy, linked to reformed madhouses, gave birth to the true Great Confinement-the age of asylumdom that would spread across continents in the nineteenth century.
Chapter 6
The Empire of Asylumdom and Its Discontents
A new consensus emerged that the mad must be segregated from society, launching the "great confinement" that dominated Western responses to mental disorder until the late twentieth century. This new "geography of suffering" created specialized experts in asylum medicine whose professional identity became inseparable from these institutions. The expansion of asylumdom became increasingly state-funded and state-administered across Europe and North America.
The paradox of asylum reform lay in its origins: the very institutions championed as humanitarian advances were born from exposing the horrors of earlier confinement. Dorothea Dix documented appalling conditions in American almshouses, finding the insane "naked, beaten with rods, and lashed into obedience!" She discovered madmen hidden in dilapidated sheds adjacent to deadhouses and women locked in dark cellars for years.
Western asylum models spread globally through imperial influence but with varying patterns. Britain's settler colonies (Canada, Australia, New Zealand) quickly built institutions mirroring British asylums. In India, the British initially shipped mad employees back to London, but eventually built facilities primarily to hide insane Europeans whose presence threatened white superiority ideology. Even independent nations eventually adopted Western asylum models. Argentina's elite embraced asylums in the mid-19th century to appear "civilized" to Europeans. China's first Western-style asylum opened in 1898 through American missionary efforts.
The York Retreat became extraordinarily influential in the English-speaking world, serving as a model for reformed asylums. With its domestic appearance, hidden bars, and perimeter ditches instead of walls, its architecture embodied its humane philosophy. Regular employment was considered "the most generally efficacious" means of promoting self-restraint, while patient comfort was "considered of the highest importance, in a curative point of view" since happiness increased patients' desire to maintain self-control.
Despite moral treatment's virtues, it presented a dilemma for physicians seeking to medicalize mental illness: it wasn't clear why doctors should administer it. Pinel had learned his techniques from lay persons with direct experience, acknowledging they possessed "detailed knowledge that is lacking in the physician." He was skeptical of most medical treatments for madness, from bloodletting to "confused polypharmacy," stating that "medication comes into the general plan as a secondary means."
Yet within twenty-five years, medicine's pre-eminence in treating mental illness was nearly complete. By 1837, the York Retreat had acquired a medical superintendent. This marked the significant moment when madness's multiple meanings were supplanted by a medical perspective, with "madness" itself becoming an objectionable term.
Chapter 7
Degeneration, Despair, and Desperate Remedies
By the 1850s, pessimism about treating madness had grown pervasive among alienists. Their inability to deliver the promised high cure rates, combined with the accumulation of chronic patients, haunted psychiatry in the late nineteenth century. Silas Weir Mitchell chided psychiatrists for presiding over "living corpses" who had "lost even the memory of hope" and sat in rows "too dull to know despair."
In France, the crisis of psychiatric legitimacy intensified through the 1860s and 1870s. Alienists faced attacks from all sides-the liberal and conservative press, politicians, and even skeptical medical professionals questioned their competence and tendency to confine the sane.
French alienists found a solution that would reinforce madness as a medical problem while justifying asylum confinement. In 1857, Benedict-Augustin Morel published his influential "Treatise on the Intellectual, Moral, and Physical Degeneracy of the Human Race." Within fifteen years, his ideas became medical orthodoxy.
This new theory positioned madness not as a product of civilization's stresses but as its antithesis-the result of biological inferiority and degeneration. Drawing on Lamarckian inheritance rather than Darwinian natural selection, madness became viewed as the price of sin, potentially paid not by the original sinner but by descendants. This theory conveniently explained psychiatry's therapeutic failings-the problem wasn't professional impotence but the very nature of mental illness itself. The mad were "tainted creatures" who lacked willpower and self-control, making them dangers to society who required confinement.
For the insane, degenerationist ideas justified permanent confinement. William Booth of the Salvation Army declared it "a crime against the race" to allow the "inveterately depraved" freedom to "infect their fellows." Asylum construction exploded-London built multiple facilities housing thousands each. Near Epsom, five barracks-asylums contained 12,000 patients.
The harsh language used to describe the mentally ill reflected degenerationist thinking. Psychiatrists referred to patients as "tainted persons," "lepers," "moral refuse," and beings with "special repulsive characters." This thinking fueled the rise of eugenics. Many American states passed laws prohibiting marriage of the "mentally unfit" and allowing their involuntary sterilization. In the landmark 1927 case Buck v. Bell, the Supreme Court upheld these laws 8-1, with Justice Oliver Wendell Holmes infamously declaring "Three generations of imbeciles are enough."
Nazi Germany took these ideas to their horrific conclusion. German psychiatrists enthusiastically participated in sterilizing 300,000-400,000 people between 1934-1939. The T-4 program systematically exterminated mental patients-"useless eaters"-first by lethal injection or shooting, then by gas chambers disguised as showers. More than 70,000 perished in eighteen months, with the total reaching a quarter million by war's end.
Chapter 8
The Psychoanalytic Interlude and Biological Revolution
The 1920s and 1930s witnessed an explosion of somatic treatments targeting mental illness across Europe and North America. This therapeutic experimentation flourished unchecked, fueled by desperate families, psychiatrists' professional ambitions, and fiscal pressures. Patients, stripped of moral agency and locked away from public view, had little ability to resist.
Many treatments have faded from memory: barbiturate-induced prolonged sleep, horse serum injections into spinal canals to produce meningitis, deliberate hypothermia experiments, and injections of strychnine, calcium, or cyanide. Others, like lobotomy and electroconvulsive therapy, spread widely and dramatically shaped public perceptions of psychiatry.
No one disputed that lobotomy produced brain damage-it was a direct surgical assault on the frontal lobes. Portuguese neurologist Egas Moniz developed the procedure in 1935. American neurologist Walter Freeman developed the transorbital lobotomy-using an ice-pick inserted under the eyelid after electroshock rendered patients unconscious. This ten-minute procedure allowed Freeman to operate on dozens of patients in a single afternoon, performing 2,400 such operations by 1957.
By the 1950s, enthusiasm for these desperate remedies began ebbing, and by the 1960s insulin comas, shock therapies and psychosurgery were condemned as psychiatric oppression. Literary and cultural critiques proved particularly damning. Ken Kesey's novel One Flew Over the Cuckoo's Nest portrayed an institution using electroshock to discipline patients, with lobotomy as the ultimate weapon against the irrepressible Randle P. McMurphy.
While institutional psychiatry spread its somatic treatments globally, a fundamentally different approach to mental illness was gaining influence. Between the world wars, Freud's theories attracted increasing popularity, bolstered partly by how trench warfare trauma lent plausibility to connections between psychological trauma and madness.
Despite hyperinflation and economic collapse following World War I, psychoanalysis flourished in German-speaking Europe during the 1920s, though its appeal remained limited by class and ethnicity. Freudian concepts infiltrated art, literature, film, advertising, and child-rearing practices. Yet curiously, most mental patients never encountered psychoanalysts, mainstream psychiatry generally viewed Freud with hostility, academic psychology rejected his ideas, and few modern patients seek psychoanalytic treatment-making its continued cultural prominence somewhat paradoxical.
The Second World War, with its unprecedented brutality, would have horrified even Freud, that prophet of pessimism. Yet ironically, this global catastrophe dramatically advanced psychoanalysis, particularly in America, where Freudian concepts would dominate psychiatry for over twenty-five years and permeate popular culture.
Chapter 9
The Pharmaceutical Revolution and Today's Dilemmas
Across Europe and North America, the physical remnants of asylum culture are disappearing-hulking, isolated buildings collapsing into ruins. The massive asylum system that once confined over 150,000 patients in England and Wales and nearly four times that many in the United States during the 1950s has been dismantled. This deinstitutionalization began first in Britain and North America before spreading to other European societies.
The downturn in American and British mental hospital populations began in the mid-1950s, coinciding with the introduction of chlorpromazine (marketed as Thorazine in the US and Largactil in Europe). Within thirteen months of FDA approval in 1954, two million Americans were taking the drug. Many psychiatrists hailed this as a breakthrough that allowed them to prescribe medications rather than rely on crude shock therapies or lobotomies.
Yet this explanation fails scrutiny. If drugs alone drove deinstitutionalization, why did France (where chlorpromazine was developed), Germany, Italy and other European countries take 25+ years to follow suit? Closer examination shows hospital populations were already declining in some regions before the drugs appeared. The influence of psychotropic drugs on deinstitutionalization was likely indirect and limited, with conscious shifts in social policy proving far more important.
While not the primary cause of deinstitutionalization, psychotropic drugs transformed psychiatry and cultural conceptions of madness. The new antipsychotics were different from earlier drugs. Chlorpromazine, synthesized in 1950 by French pharmaceutical company Rhone-Poulenc, was discovered serendipitously when naval surgeon Henri Laborit noticed it calmed psychiatric patients without causing somnolence.
Smith, Kline & French purchased the American marketing rights, renamed it Thorazine, and secured FDA approval in 1954. Through aggressive marketing to state legislatures and hospital staff, Thorazine became one of the first "blockbuster drugs," launching the psychopharmacological revolution.
This was followed by "minor tranquilizers" like Miltown, Equanil, Valium and Librium, which redefined everyday troubles as psychiatric illnesses. By 1956, one in twenty Americans was taking tranquilizers monthly. Antidepressants emerged next, beginning with Iproniazid in 1957 and tricyclics Tofranil and Elavil shortly after. The success of Prozac in the 1990s completed the transformation, with depression now considered an epidemic disease.
The late twentieth century witnessed psychiatry's return to biological explanations of mental illness, echoing nineteenth-century beliefs that madness stemmed from disordered brains and bodies. Patients and families learned to attribute mental illness to faulty brain biochemistry-defects of dopamine or serotonin shortages. This "biobabble" proved as misleading as the "psychobabble" it replaced, since the origins of major mental disorders remain largely mysterious, but as marketing copy it was invaluable.
Despite our comforting visions of scientific and medical progress, the reality for those with serious mental illness remains grim. The mentally ill die up to twenty-five years younger than the general population, with this mortality gap actually accelerating in recent decades-suggesting regression rather than progress.
Though Insel hopes to replace descriptive psychiatry with biologically-based diagnostics, this remains fantasy given our current knowledge. Despite neuroscience's remarkable expansion, its discoveries have proven of little clinical use. Madness remains an enigma-a mystery we cannot solve, whose depredations we can at best palliate.
Most critically, we cannot view the brain as an asocial or pre-social organ. Its remarkable feature is its profound sensitivity to psychosocial inputs-its very structure and functioning are products of our social environment. Human brains continue developing after birth, with environmental factors powerfully affecting neural structures. This neuroplasticity means the brain's connections, which underpin emotions and cognition, are shaped by cultural and familial environments.
Madness thus remains both a solitary affliction and a social malady-unlikely to be reduced to pure biology. The social and cultural dimensions of mental disorders, central to the story of madness throughout civilization, will not simply disappear. Madness retains its meanings, however elusive, and remains a fundamental puzzle, a reproach to reason, inescapably part of civilization itself.
