First published in Medicine Weekly in summer 2002:
Anyone who sees a psychiatrist needs her head examined, is an old one. Even older is the more serious observation in Hamlet that to “define true madness … what is’t but to be nothing else but mad?” This book doesn’t try to define madness but rather describes how madness has been defined down the years.
Sadly, the author, Roy Porter, died, only 55 years old, not long after publishing this small book. Therefore it is the last we shall have from this astonishingly prolific author. From the time of his double first in history at Cambridge University in 1968 he wrote and edited over 100 books, many of which were about the history of medicine, especially psychiatry. He was in fact made an honorary fellow by both the Royal College of Physicians and the Royal College of Psychiatrists.
In the field of medical history, in works like Patient’s Progress: doctors and doctoring in eighteenth-century England and Health for Sale: Quackery in England 1660-1850 he shifted the emphasis in medical history away from doctors onto patients. The Greatest Benefit To Mankind: A Medical History Of Humanity (1997) was his magnum opus, replacing Fielding H. Garrison’s An Introduction to the History of Medicine, published in 1922, as the standard overview textbook.
Porter’s lengthy treatment of madness, Mind-Forg’d Manacles: A History of Madness in England from the Restoration to the Regency deals with a much shorter period than the present book, which is a jaunt in comparison, parading all his favourite anecdotes from this rich but distressing source of tales.
The book is thematically organised around society’s understanding of madness down the ages, from the time when skulls were bored with tiny holes to allow demons escape, through madness as a the trial of the soul, as an imbalance of ‘the humours’, as the ‘divine fury’ of artistic genius, even as sanity in a world gone mad, or as brain chemistry gone awry. Treatments covered include exorcism, terror (for example, immersion in a tub of eels), asylums, shock therapy, psychoanalysis, and medication. The book ends with a brief survey of the current state of psychiatry.
In all this Porter highlights how changeable our ideas have been on who qualifies as insane, what causes mental illness, and how such illness should be treated. One thing that has remained, sadly, quite consistent is the tendency to mistreat sufferers. John Perceval, in his Narrative of the Treatment Received by a Gentleman, During a State of Mental Derangement (1838), wrote that he was treated ‘as if I were a piece of furniture, an image of wood, incapable of desire or will as well as judgement’. In the 1950s another former institutional inmate revealed that ‘I was not allowed to write to my best friend to tell her where to locate me … [T]he staff ignored me…. I was soon to learn that it appeared to be nothing but a callous belief that the insane to not suffer and that any problems they may express are bound to be “imaginary”.
But Foucault’s conspiracy theory of the ‘great confinement’ of mad and poor – incarceration as state control, not therapy – is seen by Porter as unfounded, ‘simplistic and over-generalised’, and is invalidated with important historical facts: ‘not until 1808 was an Act of Parliament passed even permitting the use of public funds for asylums’ in England. Freud is side-lined as having ‘scientific pretensions’: ‘Though he liked to see himself as a natural scientist, his beliefs were fated to enjoy their greatest acclaim and influence in fiction, art, and films. With his disturbing view of a self which was divided and not master in its own house, Freud became the principal myth-maestro of the twentieth century.
His assessment of the current situation is that psychiatry ‘still lacks the cognitive and professional unity enjoyed by general medicine and remains torn between bio-psychological and medical models both of its object and of its therapeutic strategies.’ Nonetheless, Porter realises, ‘more people are said to suffering – indeed claiming to be suffering – from a proliferation of psychiatric syndromes, in a “victim culture” in which benefits may appear to lie in buying into psychiatric paradigms.’ He suggests that we live in a time in which the ‘idioms of the psychological and the psychiatric replace Christianity and humanism as the ways of making sense of self’.