Madness: a brief history Roy Porter Oxford: Oxford University Press; 2002 192 pp $29.95 (cloth) ISBN 0-190280266-6
I first encountered the work of Roy Porter seven years ago, while visiting a friend in London. I was looking for something to read, and from her voluminous bookshelves she pulled down London: A Social History. Not having read much history, and even less “social history,” I was wary of that 400-page volume. I needn't have been. As Oliver Sacks opines on the dust jacket of Madness: A Brief History, Porter is “delightfully easy to read.” The engaging quality of the writing I discovered back then shines through this handsome little book from Oxford University Press.
Porter was for many years Professor of the Social History of Medicine at the Wellcome Trust Centre for the History of Medicine at University College, London. He combined his considerable abilities as historian, teacher, writer and broadcaster to put together books remarkable for their intelligence, wit and clarity. Porter is scholarly without being abstruse, and can be brief without being superficial.
To some extent, Madness: A Brief History is a pocket-sized distillation of Porter's long-standing interest in the history of psychiatry and mental illness. In 1987 he published A Social History of Madness. Four years later his Faber Book of Madness appeared. In 1995 he co-edited A History of Clinical Psychiatry: the Origin and History of Psychiatric Disorders. Over the last three decades he wrote or edited 80 books. One reviewer observed that Porter wrote faster than most people read. He was also guided by the rules of eco-friendly writing: reduce, reuse, recycle. For instance, the story of medieval mystic, Margery Kempe, appeared in A Social History of Madness; 15 years later, for Madness: A Brief History, he edited the borrowed bits to create a shorter and more energetic version.
Madness: A Brief History is a fast-paced, panoramic survey of madness through the ages, accompanied by historical highlights of the enterprise we now call psychiatry. From the outset his purpose is clear:
[T]he brief historical survey that follows makes no attempt to define true madness or fathom the nature of mental illness; it rests content with a brief, bold, and unbiased account of its history.
Porter's account starts with the Babylonians and ends with the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders. Along the way he treats us to a kaleidoscope of persons, events and institutions that includes epilepsy among the Assyrians, the Furies of the Iliad, divine possession, the Glastonbury madhouse and Bedlam Hospital, Robert Burton's Anatomy of Melancholy, the colourful roots of European psychiatry, a century of psychoanalysis (starring the “conquistador of the unconscious,” Sigmund Freud) and our present psychopharmacologic revolution.
To read Porter is to enjoy not only his lively and polemical style, but also his memorable phrasemaking: therapeutic terror, medical materialism, institutional solution, atavistic degenerationism, and myth-maestro (another reference to Freud). From Porter you can learn about Alois Alzheimer, the origin of the expression “not guilty by reason of insanity,” and who first coined the terms alcoholism and psychiaterie. (Magnus Huss in 1852, and Johann Christian Reil at the turn of the 19th century, respectively.)
Not coincidentally, I have another brief history of madness on my desk. Psychiatry in Canada: 50 years, edited by Quentin Rae-Grant, is a 300-page collection of essays on psychiatry in Canada during the second half of the 20th century. Whereas Porter's work is painted on a large canvas, this volume is a microhistory published to mark the 50th anniversary of the Canadian Psychiatric Association. Although Psychiatry in Canada differs in scope and style from Porter's book, I suspect that Porter would have agreed with one of Rae-Grant's conclusions about the long and winding road that is the history of psychiatry:
Before walking away in despair from the issue of mental illness, we should recognize that at least part of this despair may derive from the fact that we have no cures. Indeed, we have no illnesses. We have syndromes and clusters but as yet no definitive tests for our diagnoses. (p. xii)
Far from despairing, Porter is fascinated by the changing “notions” of madness, and by the shifting and ambivalent attitudes of society toward its mentally ill members. In his compressed treatment of the relatively recent history of the last century and a half, he focuses on psychiatry's struggle to justify itself as a scientific activity:
Psychiatry has typically pursued twin goals: gaining a scientific grasp of mental illness, and healing the mentally ill. These have generally been seen as inseparable, but at times one has been emphasized more than another. In the late nineteenth century the priority lay, for many psychiatrists, upon establishing their discipline as a truly scientific enterprise, capable of taking its rightful place in the pantheon of the “hard” biomedical sciences, alongside neurology and pathology, and utterly distinct from such quackish and fringy embarrassments as mesmerism and spiritualism. (p. 183)
Porter challenges the conventional picture of the history of psychiatry as one of progress and enlightenment. He delights in the human ingenuity and imagination, and in the frailty and egotism displayed throughout that eventful history. Where are we now? According to Porter, psychiatry
still lacks the cognitive and professional unity enjoyed by general medicine and remains torn between biopsychosocial and medical models. ... More people than ever swallow the medications, and perhaps even the theories, which psychiatry prescribes, and attend various sorts of therapists, as the idioms of the psychological and the psychiatric replace Christianity and humanism as the ways of making sense of self — to oneself, one's peers, and the authorities. (p. 217-8)
Madness: A Brief History will change your thinking about mental illness. For those unfamiliar with Roy Porter, it's a tasty hors d'oeuvre to an impressive collection of writing. If you've already made his acquaintance, it will be a satisfying digestif.
The sad part about writing this review is knowing that the gifted Mr. Porter died suddenly and unexpectedly in March while riding his bicycle home from work. He was 55.
Vincent Hanlon Emergency Physician Lethbridge, Alta.