Madness in Civilization: A Cultural History of Insanity, from the Bible to Freud, from the Madhouse to Modern Medicine by Andrew Scull (review)

One of our great historians of madness has given us a masterpiece. Andrew Scull’s new book is rich and learned, a feast of facts and stories, and fabulously readable. I devoured my copy when it came, and not just because I am interested in this sort of thing. I have found plenty of books in the field to be suitable narcotics.

I do differ on some points. One matter of emphasis is geographic. There are some nods to China and the Arab world, mostly at the beginning, but the book is heavily devoted to countries in the North Atlantic Treaty Organization. Latin America, Russia, Africa, and Asia receive scant attention. This is too bad, because there is lots of relevant secondary work on these parts of the world available in English now.

Scull finds the amount of scholarly attention given to psychoanalysis to be curious relative to its influence. It’s hard, of course, to quantify just how much attention is warranted, but Scull’s own account gives reason to think psychoanalysis deserves plenty of attention. He notes, for example, that in the United States, by the 1960s, the chairs of nearly all psychiatry departments were psychoanalytically oriented. And then there is its impact on other fields of medicine; Scull notes pediatrics via the work of Benjamin Spock, and psychoanalysis influenced other fields by giving an account of psychosomatic illness. And then there is psychoanalysis’s influence as model of the mind and culture more generally—as Auden famously put it, “a whole climate of opinion.” On these grounds, it demands a fair amount of scrutiny.

There runs through this book much suspicion of the treatments for madness. And some suspicion is justified. The mad have endured their share of ineffective or even abusive practices, maybe more. But I am doubtful that it is good for the field if historians do not make firm acknowledgments of clinical efficacy, whether of, for example, antipsychotic medications, psychotherapy, or electroconvulsive therapy. While it is true that outright cures for major mental illnesses are hard to come by, reduction of the suffering caused by symptoms is no small achievement. You can find evidence for this efficacy in clinical trials, or if that doesn’t impress you, in the everyday experience of clinicians, or if you don’t like that evidence, in patient testimonial. None of these treatments works perfectly, and some have adverse effects. Treatments for madness are far from unique in medicine in that regard, though. If historians downplay evidence for clinical efficacy, but stress evidence for clinical failure or abuse, we are playing against mental health professionals with a stacked deck.

Other historians of madness may have their own points of difference. That is likely to happen when you write such a capacious book. Scull’s work, also, has always derived some of its liveliness from being opinionated, though always carefully sourced and reasoned, and this book is no exception. Madness in Civilization is a great introduction to the subfield, as well as a great resource for specialists in it. It will be a classic.