While undoubtedly an enjoyable and informative read, the interest of Andrew Scull’s sweeping history of insanity for sociologists ultimately hinges on whether it can connect narrative history to broader sociological themes. Scull is more than capable of making such links. One earlier study showed how the expansion of the asylum and consolidation of psychiatry in Great Britain from 1700 to 1900 stemmed from the Weberian “disenchantment” and professional “rationalization” of the Victorian era.^{Footnote 1} Elsewhere, Scull offered a Marxian challenge to dominant explanations for the “de-institutionalization” of the mentally ill that began in the 1960s. Rather than emphasizing therapeutic innovations or benevolent policy, Scull looked beyond medicine to show how this process stemmed from the early inklings of neo-liberalism: a fiscal crisis of the state and a push to re-commoditize the mentally ill themselves by turning them into a source of profit for private nursing homes.^{Footnote 2}

In Madness in Civilization, Scull claims to choose an even broader object. Rather than writing about “psychiatry” or “asylums” or even “mental illness,” he declares himself here to be examining “madness—massive and lasting disturbances of reason, intellect, and emotions” [11]. While Foucault is Scull’s main theoretical interlocutor, implicitly the work pivots to Durkheim: Scull’s stated goal is to show, in good sociological fashion, how “the most solitary of afflictions” is in fact “indelibly part of civilization, not located outside it” [10].^{Footnote 3} Scull’s method for illustrating this point is to show that madness is a “phenomenon to be found in all known societies” [11], starting from Biblical times. Perhaps Scull should be criticized for claiming to write a universal history despite, by page one hundred, abandoning much discussion of countries outside Western Europe and North America (indeed, the vast majority of the work draws on sources focused on France, Great Britain, Germany, or the United States).

Despite this limitation, the greatest value of this work comes precisely from its vast scope. Scull reveals some surprising consistencies in the way “civilization” (at least, the “civilizations” considered by Scull) has approached “madness.” For example, sociologists have produced a rich literature on the drastic shift in American psychiatry in the 1980s from Freudian, psychological understandings of madness to biological ones, facilitating the rise and dominance of psycho-pharmaceutical treatment.^{Footnote 4} Looked at through Scull’s wider lens, though, this shift looks less like a sharp break and more a reversion to the mean. Starting as early as healers in ancient Greece, who blamed humoral imbalances (of course, more common among women) for emotional disturbances [29], “mad-doctors” have perpetually obsessed over finding a bodily root of insanity. As Scull shows, rarely have we been content to view mental illness as, well, “mental.” Freud was, indeed, one of the first to see “ravings, disturbed perceptions, and unruly emotions as worth understanding, rather than simply as expressions of a disordered brain” [289].

The search for a somatic cause of madness is closely tied to another common thread: psychiatrists’—or, before them, alienists’ or mad doctors’—enduring struggle to be accepted as legitimate practitioners of medicine. Claims to have found a physical treatment for madness, whether blinding boxes, bleeding, or beatings, have always been a “matter of great pride to psychiatrists,” insofar as they provided “visible symbols of psychiatry’s reconnection to scientific medicine and its break from early isolation and therapeutic impotence” [316]. In the end, though, their disciplines’ failure to find a convincing cure or even explanation for madness has kept those treating the mad at perpetual arm’s length from the rest of medicine. One implicit lesson to be pulled from Scull’s work is that sociological scholarship on the professions—within which psychiatry is often a crucial case^{Footnote 5}—should be attentive to the distinctively precarious nature of psychiatric expertise.

In the final chapters, Scull’s narrative transitions seamlessly into the present in a fashion that once again suggests continuity, rather than rupture. For those commentators who see advances in psycho-pharmaceutical and gene-therapy as heralding an unprecedented era of molecular-level transformations of the very nature of humanity,^{Footnote 6} Scull offers a douse of cold water. The financial appeal of psychiatric drugs to pharmaceutical companies stems not from their miraculous capacity to make individuals feel “better than well”—as Prozac’s enthusiasts declared—but their very “therapeutic impotence” [401]. All told, “The metaphysical wager that much of Western medicine embraced centuries ago, that madness had its roots in the body, has in most respects yet to pay off” [411]. You can almost imagine a future incarnation of Scull placing the pharmaceutical “revolution” alongside cold baths and lobotomies as another flailing, failing innovation in treatment.

This is not to say that Scull has much patience for the anti-psychiatric critiques that flourished in sociology (and elsewhere) in the 1960s. For him, madness’ universality across time and space proves that it is no social invention. Nor is it fair to lump all treatments together as equally malicious attempts at social control. For example, “Few would dispute the claim that asylums operated along moral treatment lines”—which sought to rehabilitate patients with incentives, rather than punishments, and encourage them to participate in maintaining the hospital community rather than chaining them to the walls—“provided a more human environment than the worst of the traditional madhouses. Well, actually, the French philosopher Michel Foucault and his followers would” [207].

It is through such swipes at Foucault that Scull stakes out his most explicit theoretical stances. Foucault, for example, lamented that, with the rise of psychiatry in early-modern Europe, a long-running dialog between reason and madness had been replaced with a “monologue of reason about madness.”^{Footnote 7} Scull disagrees. With few exceptions, civilization has never listened to what the mad have to say. Treatments over time may be more or less abusive but, in the end, the very notion of “treatment” reflects how “civilization” has invariably suppressed, silenced, and stigmatized madness.

Scull is undoubtedly more careful than Foucault with his evidence, pointing out that the French philosopher’s much evoked “Great Confinement” of the mad in 17^th century Europe misses the fact that the vast majority of the insane in this period were left with their families [127]. Nonetheless, Scull falls into some of the same traps for which he criticizes Foucault. In discussing depictions of madness in 15^th century painting and literature, Scull notes that these cultural artifacts “would tempt […] Foucault into embracing the wholly mistaken notion that these powerful paintings were representations of something real, instead of merely an artistic conceit” [115]. Yet while Foucault himself later acknowledged that his first work overemphasized depictions of madness—as opposed to the actual practices used to manage it^{Footnote 8}—discussions of such “artistic conceits” fill up Scull’s own work, raising questions of what this book is actually a history of.

In this respect, the most mundane aspect of the title is revealing. Scull writes about madness in civilization, a more extended phrasing of which might be, “Given the existence of madness, what does civilization do in response?” Some of the book’s finest moments come from doing just that, showing how different societies projected their cultural anxieties onto madness. For the Greeks, madness was proof that humanity existed at the whims of capricious gods [23]; for medieval Christians, that humans were pawns in a cosmic struggle between God and the devil [77]. Such observations make a strong case for viewing madness as a window into the shifting preoccupations of the collective social consciousness (again, hearkening to Durkheim), with madness variously embodying the antithesis of Enlightenment reason, asylums encapsulating the ambitions of the Victorian era, and neurosis elites’ fears of the costs of modernity. Perhaps Western societies’ present response to severe mental illness—making it “largely disappear into the families, into the street, or into liminal boarding or nursing homes” [375-377]—not to mention prisons—tells us something about neo-liberal civilization, too.

Surprisingly, though, scant space in the book is given to madness itself. While Scull’s realism about mad people as having a real and grave affliction, which has led to their abuse in virtually all human societies, is appreciated, his approach nonetheless leaves out some of the more current theorizing about the relationship between individual conditions and social responses. As philosopher Ian Hacking demonstrates, social reactions to madness “loop” back, as the mad both experience and act upon their labeling as “mad” in ways that transform the meaning of madness itself.^{Footnote 9} Scull gives us glimpses of this when, for example, we see how the 19^th century English upper-classes “eagerly embraced” nervousness and hysteria as emblems of their delicate and sophisticated sensibilities [162]. This “looping” opened up the possibility that variants of madness were not confined to the margins of society, but instead widespread. Yet aside from moments like this, Scull has left out the processes by which conditions are classified as “madness,” people are placed in that category, and those same individuals struggle to redefine these labels.

Perhaps this omission is deliberate. After all, even with the rise of today’s mental “patients'” or “survivors’” movements, the mad have never had much agency in determining their place in civilization, as Scull shows. Nonetheless, for a book with such broad ambitions, it is surprising that so little attention is given to the phenomenological experience of madness itself. It barely needs arguing that, if we define madness as “massive […] disturbances of reason, intellect, and emotions” [11], we need to consider how “reason, intellect, and emotions” themselves are expressed and defined at different historical moments. Indeed, here might be a chance for Scull to explore how society’s response to madness, and the mad themselves, can change the meaning of the basic understandings and categories on which distinctive social orders rest. At the very least, had Scull more thoroughly considered the large anthropological literature on madness outside the Western core, his implicit assumption that we can take “madness” for granted would be untenable.

In the end, Scull’s well-written and (insofar as it is possible, given the subject matter) enjoyable book succeeds in showing that “madness is indelibly part of civilization, not located outside it” [10]. But for sociologists—who, frankly, are probably not the book’s target audience—this is hardly a startling conclusion. More interesting, and more profoundly Durkheimian, is the assertion that madness “cannot be ignored,” challenging as it does “the sense of a common, shared reality […] and threatening, both symbolically and practically, the very foundations of social order” [24]. Such a claim, if supported, would make a real case for continuing in the vein of older social theorists—from Goffman to Foucault—in viewing madness as a key object of analysis not just in medical sociology, but also in sociology in general. But Scull’s history does not really demonstrate that madness has any such centrality. It is certainly not clear that madness—far from being relegated to the margins of society—is something which “insistently invades our consciousness and our daily lives” [10]. While for those who want to survey the ongoing tragedy of madness in civilization there are few better introductions than this, the book leaves unanswered the more interesting question of if and how madness makes different social orders.