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a brave attempt at a massive, contraversial subject
on 8 July 2002
Perhaps nobody but the late great Roy Porter (our greatest medical historian as the British Medical Journal's obituary put it) could have attempted to summarise the history of madness in 241 pages. Certainly nobody could have made such a good, if ultimately somewhat flawed, attempt.
Starting with what is good - Roy Porter gives us an excellent overview and summary of the whole history of madness moving from earliest times through to the Prozac present. His writing is crisp and extremely readable throughout and he is generally fair and unbiased. He wisely sidesteps a definition of madness and gets on with telling the story. Porter discusses wider social and cultural issues alongside the personalities and principles, tackling Michel Focault with exceptional verve and perception. He is excellent on the dichotomies and controversies and debates - external v internal causes of madness, psychiatry v anti-psychiatry, psychology v neurology, Freud v Jung, organic v functional disease, psychotherapy v medication, the role and reason for asylums. The coverage of early modern Europe, including the philosophical contributions of Locke and Descartes, the rationalisation of madness as a part of the Enlightenment project and the slow rise of humane attitudes to the mentally ill, with attempts to care and cure in early industrial societies are all exceptional. Finally, Roy Porter gives a chapter to the voices of the mad/"mad" themselves, fascinating case vigenettes which he resists the temptation to diagnose.
But this vast scope of coverage comes at a price. Some issues, especially in the history of 20th century psychiatry (which chapter is just too short and compressed) are grossly over-simplified . The discussion of drugs for mental illness which have revolutionised psychiatry and relieved so much human suffering and misery gets just over a page. While the discussion of Freud and psychoanalysis is excellent, some of the less well-known but equally important pioneers of the 19th century get little space and less analysis. No mention is made of the incredible recent advances in neurosciences, brain imaging, genetics and epidemiology which are revealing much about the causes of mental illness. It is too easy to poke fun at the changing psychiatric landscape with its "new" diagnoses, epitomised by the DSM-IV manual, but the recognition of entities such as Post Traumatic Stress Disorder has been as much cultural, social and political as medical. Apart from some mention of early Islamic approaches to madness and a passing mention of Japan there is nothing about non-Western psychiatry (although Porter does tell us the madness is found in all cultures and societies). And perhaps most glaring of all, not a word about the appalling abuse of psychiatry, for political purposes, in the former Soviet Union.
But despite these reservations, this is still an attractive and well-presented introduction to the subject, there seems no equivalent brief study, and frankly the issues Roy Porter skates over have had whole libraries written about them. As ever Porter provides an excellent and thorough bibliography where those whose appetite is whetted can explore the topics to their heart's (or should it be mind's (or should it be brain's)) delight.