The history of psychiatry is long and circuitous. Indeed, the generic term “madness” has been defined in many contexts: from divinely inspired to demonically possessed, from damaged by colored humors to infected with worms or parasites. Medical and societal biases have steered nosographic classifications of madness, and technological advances of each era have been systematically applied to decipher the mysteries of this medical entity.
In Madness: A Brief History, Roy Porter, an author of over 80 books who died in March, approaches this topic with a survey of Western views from pre-antiquity to the present. In seven somewhat chronologically organized chapters – each covering a large period defined primarily by a unifying theme – he offers his version of a “brief, bold, and unbiased” account of the history of madness.
The author frames the series of chapters with an introduction and conclusion to place the material and themes in a contextual framework. The chapters stand largely independently of one another without unifying themes to link them, but each is well written and interesting to read in a casual manner.
The chapter on Gods and Demons examines the ancient views of madness and the myths that arose around the realities of mental illness.
In the Rationality of Madness, rationalism and the beginnings of a movement to medicalize madness emerge and move physicians towards the development of medical constructs of psychiatry.
Fools and Folly examines the interface between madness and genius, the creative dichotomies seen in mental illness, and their medical justifications. Locking Up focuses on the history of asylums, developed on the one hand to separate and stigmatize inmates, but on the other hand, offering a venue for specialized and focused expert care.
The Rise of Psychiatry deals with the 19th century development of psychiatry as a medical specialty, distinct from internal medicine and neurology. The separation took on different medico-political hues in different countries – with differing results in the US, Great Britain, France, and Germany.
The chapter, Mad, examines the different perceptions of psychiatric disease, links between depression and psychosis, and artistic expression of madness in art and literature. The last chapter, The Century of Psychoanalysis, examines the modern era of the 20th century and the positive and negative impacts of the Freudian movement, especially in the delineation of psychological elements of madness within subjects without clinical illness.
THE DEARTH OF DETAIL
The author's engaging writing style and approach to the subject will likely suffice to entertain and globally educate a general reading audience. For neurologists, however, the fascinating dimensions of the actual history of madness are already well enough known and complex to make “brief, bold, and unbiased” an inadequate formula.
Readers with a background in neuroscience and medicine may find the book too brief, lacking in detail or development. The dearth of references and primary source citations render certain statements as far-flung and unsubstantiated generalities. For example, the sections entitled “Psychiatry–French style” and “Psychiatry–German style,” each given between four and eight pages, are reductionist in overstating political polarities.
The major differences in medical approaches may be schematized geographically with the Rhine River as a landmark division, but in fact the proper geographical distinction was within the universities themselves.
A differing emphasis on the role of the hospital versus the laboratory as the geographical focal point of scientific progress is key to an understanding of different cultural views of medical education and research. This important distinction, although exemplified in France and the German states, was widespread with subtle distinctions throughout Europe; it pivotally influenced the development of all specialties in medicine in the late 19th century. Because the dichotomy was particularly important in psychiatry, a detailed discussion of this conflict and the resultant implications during peacetime and wartime would have been worthy of treatment.
Though bold in attempting to present many ideas on the origins of psychiatric illness, the attempt to remain unbiased results in too many concepts that are too thinly developed. The superficiality and brevity of the text leaves the neurologist asking, “But what about this…?” over and over again.
The interfaces between neurology and psychiatry and between internal medicine and psychiatry provided the medical foundation to develop an anatomical and neurochemical basis for psychiatry. This evolving and fertile interplay among disciplines is inadequately prioritized in a text that overemphasizes the independence of psychiatry as a medical specialty.
As a result, Madness: A Brief History will have an awkward fit in the contemporary neurologist's activity schedule. When one sits down with a new book from Oxford University Press, the neurologist rightfully anticipates a reading challenge with penetrating chapters, well-referenced materials, and source documents as the background: in short, a scholarly analysis that appropriately addresses the wild and tempestuous ambiguities of the actual story of madness in medical history. To wrestle with this pleasure, the neurologist will need to look further.