Making sense of madness

The polymathic Roy Porter produces new books like other people write articles. It seems only yesterday that I was reading his Enlightenment, a work whose jejune thesis and reliance on quotation reflected the speed of its compilation. This short history of madness, a subject that lies four-square in Porter's field (he is a Professor of the Social History of Medicine), is more convincing and better done. He gives us a sure-footed and informative summary of the diagnosis and treatment of insanity from the days of religious heresy-hunting - which, like Soviet and Nazi persecution, could provide its own justification by actually driving people mad - to the " psychiatric century", whose extravagances it would be premature to believe we have left behind.

Porter knows how to keep us reading and case histories provide moments of ghoulish entertainment, such as the man who was afraid to piss for fear of drowning the world, or the one who was convinced he was made of glass. Yet grimness is in copious supply, especially in his vivid accounts of early asylums. He disclaims any attempt to define true insanity, but distances himself from the still fashionable Michel Foucault, who maintained that madness was a cultural construct, ie, a product of "the system". (Before dying of it, he said the same about Aids - see the virulent controversy currently enlivening the letters page of the TLS).

Madness, its causes and cures is one area of medicine where linear progress is less than evident, and Porter reminds us not only of the brave pioneers of humane treatment for the mentally sick, but of how many self-proclaimed experts in the field turned out to be somewhat touched themselves. Because of the limits of knowledge and our underlying fears, treatment of the insane appears to have been alarmingly subject to fashion, and the lurch of opinion against institutionalisation, a growth industry throughout Europe in Victorian times, is now swinging back for many categories of the mentally ill.

"More people seem to be diagnosed as suffering from more psychiatric disorders than ever: is that progress?" Porter asks in conclusion. That is what we want to know, but he hasn't the space to tell us. It would have been particularly interesting to hear him on the modern equivalents of crazes that, throughout history, have reduced large numbers of people to a state of semi-suppressed hysteria, notably in medieval times. If a 19th century doctor, George M Beard, could say that "American nervousness is a product of American civilisation", meaning the telegraph, the railroad, the Press and the Wall Street rat race, what would he say of turbo-charged western mass society today? Porter has an unusually sane approach to a subject that - as he shows - has bred centuries of charlatans, and an update by him of that superb mid-Victorian classic, Extraordinary Popular Delusions and the Madness of Crowds by Charles Mackay, could be a great contribution to an understanding of our routine, daily dementia. Meanwhile, this brisk account is a perfect introduction, not least because it leaves you wanting more.