Roy Porter (1)Besprekingen

12/4/22

Roy Porter's "Madmen: A Social History of Madhouses, Mad-Doctors and Lunatics" was far superior to his "A Social History of Madness." In fact, a majority of the latter appears throughout this one, except with better narrative flow and context.

The title is misleading though. It is a social history of madness in the 18th century specifically, and even then ONLY in England. Which I don't mind, as the 18th century is my specialty, but someone else might. Among the excerpts from contemporary publications and historically (in)famous name drops, it covers the rise of psychiatry as a science, the "English Malady" and how "having nerves was almost as much a status symbol as having taste" (think Mrs. Bennet from Pride and Prejudice!), the practice of boarding "lunatiks" and the lucrative business of private madhouses, St. Luke's Asylum vs Bethlem Hospital, the York Retreat and humane treatment, and the myth of the Great Confinement.

Overall a fascinating read even if the author is a little repetitive at times. I learned quite a lot and took a significant amount of notes!

There exist few ways to understand something better than understanding its history. Nuanced details make more sense when attached to the historical narrative. Such is certainly the case in medicine, the universal human struggle against death. This book, an edited collection of histories of various aspects of medicine, offers these explanations with clarity and erudition. It offers hard science commingled with human insight – a coupling appropriate for the task of healing.

Students of medicine or even future students of medicine would do well to pay heed to this book. It presents a comprehensive picture of the medical enterprise. It offers insight into why individuals look for healing and what that healing consists of. While having a particular focus on the West – and especially Britain (due to its Cambridge origins) – this book attempts to integrate other forms of healing into its analyses, like homeopathy, acupuncture, and so-called alternative medicine. American medicine is frequently referenced, perhaps because of its disproportionate impact on world medicine through research.

Medical research is also well-covered in this history alongside clinical medicine. Philosophical underpinnings, like the mechanistic view of the body popularized in the Renaissance, are explained in light of the developing influence they garnered. This book does not explain in detail non-Western forms of medicine, but straightforwardly admits this fact in the text. It does treat those forms of medicine in passing.

As alluded to in the title, numerous illustrations are provided and deepen readers’ experiences. Indeed, in a sensory field like medicine, these images are almost essential. A newer edition of this book exists, one without “illustrated” in the title; I do not know if these images exist in that text, but I chose this book because of the need for good images. Indeed, this book could serve as a good book for a physician’s or nurse’s coffee table. For those looking to dig deeper into particular topics in the history of medicine, an appendix of references is provided.

This book meets several potential audiences. Medical trainees are first among those. Anyone interested in the medical enterprise in an international setting – its past, present, and future – can benefit from a read. Also, current practitioners of the medical arts can brush up on their knowledge of the past. Mysteries of the present can be explained through stories of the past – I found this to be the case several times during my reading. This book deals with an important topic, one often overlooked by education’s science-heavy curricula. Perhaps another generation can benefit from reading its contents.

I tried. I coffee'ed up and put in the time. Multiple reading sessions, high hopes and the kind of determination only an accomplished sufferer of OCD could understand. I didn't want to NOT read this. So 200 pages in and it's over.

Roy just couldn't stop trying to prove his point before he had even bothered to make it. I'm all for backing a dream and making your case strongly. Impassioned authorship typically makes for a great read. There was just too much philosophy and far too little content. Please teach me about the Enlightenment in Britain before trying to talk me into its importance. Making arguments using facts that I have yet to learn (and was hoping to learn in this book) is confusing and de-motivating.

So that's all. I'm quitting you book.

Edward Gibbon is the rare historian whose impact went far beyond his profession to leave an indelible impression upon Western thought. This is entirely due to his most famous work, The Decline and Fall of the Roman Empire, which as Roy Porter notes in the introduction to this book, remains so well known today that “people who cannot name any other work of history can rattle off the phrase Decline and Fall.” Yet to reduce Gibbon’s classic to a mere phrase glosses over his complex thinking about the past and the forces that drive history. Porter demonstrates this in a compact study that describes Gibbon’s historical vision, how he developed it, and the ways it was reflected in his foremost work.

Porter begins his analysis by summarizing the state of historical thought in Gibbon’s time. As he explains, it was a historically minded age that benefited from the efforts that had been invested over the previous century in gathering texts and facts. Yet this material typically was presented without any real effort at interpretation, which resulted in a paradox: a land “saturated in history” but without works of insightful social analysis. As a child, the precocious Gibbon benefited from this saturation through an early immersion in many of these texts. The books kindled a passion for learning, which was refined both at Oxford University and an extended stay in Lausanne. It was during his time in Switzerland that Gibbon both honed his linguistic abilities and gained greater exposure to the Enlightenment ideas then current in Europe. It was a period that would equip him well for his greatest project.

Upon his return to England in 1765 Gibbon embarked upon a career as a writer. Though he wrote widely about both literature and history, Porter understandably focuses his examination of Gibbon’s ideas on the Decline and Fall. After taking a chapter to summarize the book, he elaborates on Gibbon’s thinking in three chapters that address the key themes within it: power, religion, and civilization in the face of barbarism. Through them he details the ways in which Gibbon analyzed the history of imperial Rome through the lens of Enlightenment thinking, seeing with it the flaws of Christianity and an important object lesson about the loss of liberty to despotism. Porter is frank about the flaws of Gibbon’s book, including its slighting of Islamic writings and its anti-Byzantine bias. Yet he also pays tribute to the many strengths of his work, making it clear how Gibbon’s fine prose style and his perceptive arguments contributed both to the book’s success and its endurance as a work of historical literature down to the present day.

In examining Gibbon’s work, Porter demonstrates his own gifts as a historian and writer. Though he occasionally indulges himself with a flowery phrase, this never gets in the way of his analysis of Gibbon’s thinking. Because of this, his book makes for an admirable study of Gibbon as a “philosophical historian” who both embodied and transcended his age. Readers would be well advised to have a copy of Decline and Fall handy while they read it, though, because while it’s perfectly possible to enjoy Porter’s book without it, most will want to read (or re-read) Gibbon’s monumental study for themselves once they’re through with it.

Providing an overview of the intellectual discoveries of this exciting period of British history, Roy Porter’s book is dense and benefits from an existing knowledge of the history he wishes to tell. Although an understanding of the changes to religious thought during the period are impotence in understanding why cultural development was different from most of the continent, I unfortunately did not find this engaging.

Starts with consideration of whether there was a British Enlightenment, when it was less theoretical than Voltaire/Rousseau in France. Highlighting that the British Enlightenment started earlier, as a consequence of the political settlement of 1688 which reduced the power of crown and church, and was more pragmatic and empirical, rather than revolutionary.
Luck and logic meant that with George I’s succession in 1714, ...the personal powers of the Crown and the pretensions of High-flying bishops were curbed in what proved to be an unshakable commitment to the quadruple alliance of freedom, Protestantism, patriotism and prosperity. (Page 30)
Chapter 3, Clearing away the rubbish, discusses Hobbes and Locke as prime philosophers of the British Enlightenment, championing Empiricism as the basis upon which knowledge should be based.
Print Culture emphasising the importance of the lack of censorship, which had been reintroduced at the Reformation (1660 with return of Charles II) lapsing after the Glorious Revolution (1688 with William III) with the Licensing Act lapsing in 1695. This made British print culture, especially newspapers, very different from the continent, where censorship by Crown and Church was far more widespread.

I really did not finish this book. I looked at all the pictures and skimmed the last half. The photos are the best part about this book. The text is pretty boring...

For an overview of how western cultures have explained and treated insanity from its first mention in recorded history, this little volume does its job. It's a bit dry and clinical at points, but overall a quick and interesting read for anyone who likes to read psychology.

The Analytical Table of Contents is a list of sciences.

I think I first heard of this book way back when I was at university in Finland and did a British and Irish studies module about London in literature—it has therefore spent over fifteen years on my TBR list. But better late than never: when I came across it in a charity shop six weeks ago I rushed to buy it and didn't waste much time picking it up to read (unlike some other books on my shelves). And although the book doesn't reach the present—it comes to a somewhat pessimistic outlook for London coming out of the Thatcher era—some of its final thoughts about the tourist London, the rich foreign houseowner's London still seem relevant, even if investment in transport has evidently increased and the mayor brought a new element in the question of who governs London.

A great introduction to the history of Mental Illness. He starts from the earliest time of mental illness and to our modern day. Roy does a good job of delineating each era. I learnt a lot of stories, they were intriguing. It seems that, the issue of treating the individual as a human being is important. I am not sure if this is being followed everywhere. A person suffering from mental illness might be brushed aside and thought of as a beast. A lot of people, who were deemed unfit for society were tied into shackles and removed from society.

Now, Roy raises key concerns about institutions and developments through history. Initially Religious schools handled these cases, there were some positive results, however, this segment was taken over by affluent families. It seemed that from the reading, people from religious schools might put more empathy, serving people as a part of their life. This may not be necessarily true in all cases, but there's more possibility of them being better. Initially, treating these people were secretive, but after 1800's Psychiatry started to enter public domain as a credible employment. He seems to suggest the Moral therapy was successful in America in the beginning of 1800's but by the end of the century, Psychologists became more interested in the disease than patient. One thing, which I was surprised to learn is that in, every progress in this field, there's a philosophical backbone presupposed, for example: John Locke provided the lockean thinking sets for rationalizing illness, Darwin influenced Freud.

Overall, a great read.

Deus Vult
Gottfried

A great introduction to the history of Mental Illness. He starts from the earliest time of mental illness and to our modern day. Roy does a good job of delineating each era. I learnt a lot of stories, they were intriguing. It seems that, the issue of treating the individual as a human being is important. I am not sure if this is being followed everywhere. A person suffering from mental illness might be brushed aside and thought of as a beast. A lot of people, who were deemed unfit for society were tied into shackles and removed from society.

Now, Roy raises key concerns about institutions and developments through history. Initially Religious schools handled these cases, there were some positive results, however, this segment was taken over by affluent families. It seemed that from the reading, people from religious schools might put more empathy, serving people as a part of their life. This may not be necessarily true in all cases, but there's more possibility of them being better. Initially, treating these people were secretive, but after 1800's Psychiatry started to enter public domain as a credible employment. He seems to suggest the Moral therapy was successful in America in the beginning of 1800's but by the end of the century, Psychologists became more interested in the disease than patient. One thing, which I was surprised to learn is that in, every progress in this field, there's a philosophical backbone presupposed, for example: John Locke provided the lockean thinking sets for rationalizing illness, Darwin influenced Freud.

Overall, a great read.

Deus Vult
Gottfried

Disappointing, I liked his history of medicine and keen to follow through on the Enlightenment after reading A C Grayling. This is a kind of omnium gatherum of British intellectual life in the whole period from Restoration to Waterloo. Darts about confusingly in the chronology. But worse, crams in detailed lists about minor figures which further baffled me. Example: "Benjamin Martin lectured in Gloucester Salisbury Newbury Oxford, Chichester Bath Reading York Scarborough and Ipswich" !!! And an annoying stylistic mannerism of alliteration crops up on almost every page, such as "harbingers of hope" , "dark dilapidated and dangerous", reaching its finest flourish with a queer quintet: "fictions, frauds fantasies fables or fallacies". I am as great a fan of the Anglo-Saxon manner as any, but this, once noticed, is like watching a speaker with a nervous tic. Perhaps more fundamentally, the book's thesis is that the British aspect of the Enlightenment has been neglected. Well, the "Scottish Enlightenment" certainly hasn't: I've been aware of it since Hume was on my reading lists at Oxford back in the 60s; and it's implied in Edinburgh's soubriquet "Athens of the North". As for the Enlightenment's use of the metaphor of light which forms the base of his opening it was hardly new, even perhaps a cliché of philosophy, going back at least to Plato.

The defects of this book are many, but it would hurt to give it less than four stars and, the avoidance of pain being one of Porter's main themes, I will stick to a suitably thematic rating. There are delights aplenty to be mined in this compendious history, and a myriad reasons, if you still needed any, to fall down on your knees and give thanks that we live in an age of anaesthetic and antibiotics.

Things have certainly come a long way since – to pick an example almost at random from the early pages – doctors were recommending crocodile-dung pessaries as a form of contraception, as they were in Pharaonic Egypt. (Presumably they worked on the principle that they were a serious mood-killer.) And in general, you're left with a strong impression of quite how slow and painstaking progress has been: every basic drug and vitamin pill today, every vaccination and course of antibiotics, is founded on a centuries-long, incremental advance in knowledge that often took several steps backwards for every shuffle forwards.

In 1826, two Italians finally identify the pain-relieving element salicin in willow-bark; it's purified three years later by a French chemist; meanwhile, a Swiss pharmacist extracts a related substance from meadowsweet, and a German researcher uses it to obtain salicylic acid; Gerhardt works out its molecular structure in 1853, and Hoffmann finally synthesises it as acetylsalicylic acid which, in 1899, is renamed aspirin. Similar stories can be retailed for any other substance, and they give you an idea of the scale of knowledge that is being casually discarded by the sort of people who rail against "unnatural" chemicals.

Porter is at his best when he slows down long enough to make these narratives clear. When he fails to do so, the book can rattle through names and dates at a bit of a gallop – the chapters devoted to non-Western forms of medicine in particular, while welcome, seem especially cursory. Luckily, Porter has a great flair for making the kind of quick, thumbnail biographies that a book like this depends on – take, for instance, this potted story of one of the pioneers of dental anaesthesia:

In December 1844, the dentist Horace Wells (1815–48) went to a fair in Hartford, Connecticut, where ‘Professor’ Gardner Colton (1814–98) was giving an exhibition of ‘Exhilarating or Laughing Gas’. Curious whether it could be used for painless tooth extraction, Wells offered himself: Colton administered the gas while Dr John Riggs yanked out a molar. ‘A new era of tooth-pulling!’ Wells exclaimed, on coming round. Eager to exploit his breakthrough, he built a laughing-gas apparatus: a bellows with a tube stuck into the patient's mouth. Demonstrating it in the dentistry class of John C. Warren (1778–1856) at the Massachusetts General Hospital, he botched the procedure, however, and his patient suffered agony. Wells lost medical support, grew depressed, became addicted to chloroform and, after arrest in New York for hurling sulphuric acid at two prostitutes, committed suicide in jail.

Well, that escalated quickly…

Another theme that becomes clear is how far research is in advance of effective treatment. This is something we're familiar with today, when hardly a week seems to go by without another cancer breakthrough in mice or Alzheimer's regression in lab samples, yet seemingly without any practical results ever filtering through to humans in hospitals. Such has always been the case. Matthew Baillie was already complaining about it in the eighteenth century: ‘I know better perhaps than another man, from my knowledge of anatomy, how to discover disease, but when I have done so, I don't know better how to cure it.’ This sense of what Porter calls ‘medicine's Sisyphean strife’ is especially acute in the age of antibiotics, which can't be developed nearly as fast as bacteria can evolve immunity.

Then again, before bacteria were understood, things were infinitely worse. Indeed before Joseph Lister introduced the idea of germ theory, sepsis was astonishingly prevalent. Doctors would waltz in off the street, chuck a bloody apron on over their clothes, and start operating, perhaps with a quick rinse of the hands if you were lucky. There are stories in here of doctors needing a plaster, and simply opening a drawer filled to the brim with plasters of every kind that had been used and reused on patients suffering from every imaginable disease, and then just put back in the drawer after use. As a consequence, surgery was insanely risky. ‘Every single one of the seventy amputations the aged Nélaton performed during the Commune (1871) resulted in death.’

The vast historical sweep offered by a book like this also allows you to see many familiar things in a new way. Nicholas Culpeper, for instance, whose Herbal sits on my shelves and whom I had always vaguely imagined to be a kind of staid proto-botanist, is here presented as part of a grand anarchic tradition of ‘Paracelsan iatrochemistry’, which was all about promoting the values of homespun wisdom against the hegemonic early equivalent of Big Pharma (namely, the College of Physicians). I also see that homoeopathy, with its stress on purity and minimal dosage, seems a lot less ridiculous in the context of the huge, almost unregulated cocktails of drugs that were being sloshed about when it was developed in the eighteenth century.

As for the state of modern medicine, Porter (writing twenty years ago) is circumspect but downbeat. Medicine, he notes, ‘has bedded down with authority in the modern state’, and the huge advances in medical science have only shifted the focus from acute to chronic diseases. ‘Its triumphs are dissolving in disorientations.’ In the United States in particular, he is alarmed by the free-market capitalist approach: ‘Medical consumerism – like all sorts of consumerism, but more menacingly – is designed to be unsatisfying.’ And this is linked to a creeping pathologisation of normal life.

The root of the trouble is structural. It is endemic to a system in which an expanding medical establishment, faced with a healthier population, is driven to medicalising normal events like menopause, converting risks into diseases, and treating trivial complaints with fancy procedures. Doctors and ‘consumers’ are becoming locked within a fantasy that everyone has something wrong with them, everyone and everything can be cured.

Here we see again one of Porter's most admirable qualities – his focus on patients. This is not just a history of medical research, but a history also of the way doctors behave towards the public, and the relationships we have with our bodies and with our medical experts. Porter – presenting himself too as an expert – is well aware that being nice is not necessarily what people want. I detected a hint of approbation in his anecdote about the English surgeon John Abernethy, who was apparently in the habit of barking at fat ladies, ‘Madam, buy a skipping-rope’ – ‘yet,’ Porter notes slyly, ‘he was in demand.’

Although this history starts at the beginning of London, it reaches the Reformation by page 45 (of over 400 pages) so it i primarily about early modern and modern London

Scholarly discussion of body & soul in Britain in 18th & 19th centuries. A bit too scholarly for me.
Read June 2007

OK as far as it goes. not much news to me, having read his more chunky vol (Greatest Benefit) some years ago.

This is a good introduction to the evolution of western medicine. The introduction says that this is a skim through the topic, and I suppose I can't really complain too much about it feeling very superficial. The chapters were themed, with that on the evolution of germs and illness being the one I found the most interesting. There is a pretty extensive further reading list, and I can see a number of those making it onto the wish list. Good, but it left me wanting more.

This is one of those ‘surrogate’ books – I bought it because I really wanted something else, so any disappointment is my own fault.

The book I wanted was Porter's The Greatest Benefit to Mankind, his mammoth tome on the history of medicine, but my friendly neighbourhood bookshops never seem to have it when I'm in the mood. Instead, I bought this, which I thought might tide me over.

To be fair, the clue is in the title. This history of medicine really is short – if you take off the notes, bibliography and the many full-page illustrations, you're left with barely 150 pages of text. (Edit: I just counted, it's actually 130.) Like a literary amuse-bouche, I thought it might whet my appetite for the bigger version (excuse the dangling modifier), but despite the clear labelling I unfortunately found it more frustrating than stimulating.

The approach is thematic: eight chapters, each dealing with a different aspect of medicine, including disease itself, anatomy, surgery, the hospital, and so on. So we have a score of pages on each, running very briskly from antiquity to now, before resetting the clock again at the start of the next chapter. Porter's prose is as wonderful as ever, and his conclusions typically judicious. But the frenetic pace doesn't show off his talents to best effect, and the merciless effort to pare things down to the essentials means there's little room for all the grisly anecdotes of mediaeval births and eighteenth-century amputations that you want from something like this.

My preconceptions aside, this is a solid grounding in the story so far, and it will bring you up to speed. It will also have you thanking all the gods, once again, that you were born in the era of anaesthetics and antibiotics (although, as always, you can't help wondering what future generations will consider appalling about our own time).

It has some interesting things to say about modern medicine too, especially the drive towards healthcare-as-business in the US: I was amazed to read that one head of the Hospital Corporation of America was a former fast-food manager who said approvingly that ‘the growth potential in hospitals is unlimited: it's even better than Kentucky Fried Chicken’. ‘In the USA health insurance became a lasting political football,’ Porter comments mildly in 2002. (Oh Roy, if you only knew.)

‘Compulsory Health Insurance,’ declared one Brooklyn physician, ‘is an Un-American, Unsafe, Uneconomic, Unscientific, Unfair and Unscrupulous type of Legislation supported by…Misguided Clergymen and Hysterical Women.’

Porter is surprisingly ambivalent when it comes to giving an overall verdict on modern medicine, taking the view that improvements in life expectancy and pain relief are offset by commercialisation and a dubious record in how well western techniques have been exported to the developing world. (That is, investing in basic hygiene and nutrition might have been better than exporting expensive pharmaceuticals.)

I can't give this less than three stars, because the facts are all there and he writes beautifully. Unfortunately, the fact is that I wanted a lobster thermidore and I ended up nibbling a breadstick.

No Characters Need Apply.

That might be the motto of this collection of biographies. This is a biographical dictionary of scientists, but casual readers beware: It's about the science itself far more than it is about the people. Scientists, after all, are quirky, and many of them had lively lives outside of the lab. You won't see much of that here -- this isn't the place to learn (e.g.) that Marie Curie was a strongly depressive autistic who, as a widow, had an affair with a scientist five years her junior. Or about Albert Einstein's illegitimate son. Or Isaac Newton's rages.

And -- guess what -- that can be good. The biographies here are almost like a bibliography of work done, which is what really matters about scientists. Oh, the personal stuff would be fun, too -- but the book is already huge. There wouldn't be room for that in a reasonable space.

It does mean that, if you really want to find out about any particular scientist -- even a very important one -- you'll need a different sort of reference. But that's all right. Within its limits, this is an excellent book, thorough, readable, and well-researched.

Took a while, but this was an excellent, readable book about life and society in eighteenth-century Britain (an era that gets mysteriously overlooked, despite people's interested in France at the same period and the slew of Victorian novels set in that time). I learned a lot, and understanding the eighteenth century is so important to putting the Regency and Victorian periods in perspective.

This is a massive survey of medicine in history. It is not only about physicians, but about the relations of humans to sickness and healing. Roy Porter is also opinionated, and unafraid to state his opinions, generally skeptical of claims of modern medicine, and supportive of the wisdom of the people with regards to their health. He points out, as is well known, that up to about 1935, when sulfa drugs became available, that doctors were powerless against common infections. He warns against the hubris of public health officials in the face of epidemic viruses from Africa. His discussion of physician-patient interactions, and the National Health Service in Britain, did set me thinking about my interactions with patients

Roy Porter is mostly known for his books on the history of medicine and the development of medical practice in Europe. “Madmen” is Porter’s attempt at outlining the changes in the care of “lunatics” (as the subtitle puts it), mostly during Georgian England. The book traces the different approaches to various mental illnesses from the time of humoralism up until the birth of what can be recognized as modern-day psychiatry in the early nineteenth century.

Porter begins by challenging Foucault’s concept of the Great Confinement, in which unreasonable members of society were institutionalized in large numbers. According to Foucault, before the Great Confinement folly had “a liberty and truth of its own, engaging in a dialogue with reason” but afterwards became disqualified, abominated, and reduced to pure negation (unreason). Foucault also maintains that it was it mostly the poor who were institutionalized by the rising middle classes. Porter challenges this as historically inaccurate at least in England; instead, the progress was slow and gradual. Also, “it is a key contention for Foucault that the Great Confinement was driven by the powerful to police the poor … but it would be a mistake to underestimate the numbers of bourgeois, gentry, and nobility who were also being confined” (p. 21).

Porter gives an historical account of the four-fold humoralism (blood, phlegm, yellow bile, and black bile) as a way of explaining how rational, mortal men could attain balance with the cosmos; aetiologies of sickness were also explained as an imbalance between the humors well into the eighteenth century. Even though there was a medical tendency to somatize mental illness, elements in the culture (including Richard Burton, author of “The Anatomy of Melancholy,” and himself a renowned melancholic) portrayed it as a kind of psychomachia – literally, a battle between the rational and irrational parts of the soul. In later Georgian England, insanity became something to be pitied, aided by Locke’s conception of madness as a false association of ideas, instead of “the overthrow of noble reason by base passions”

While confinement of the insane did exist before around 1800, it was in private institutions, and sometimes in churches. It wasn’t until after this date that the state began to demand confinement for lunatics in subsidized asylums. Before this, going back even to the Restoration, many madhouses were actually private residences – indeed, that’s even how the word “madhouse” came about – in an age before licensing and regulation. These enterprises could be greatly lucrative for the people running them, since the owners could mandate that the lunatics stay there indefinitely while they collected the money from the lunatics’ family members. The Act for Regulating Private Madhouses of 1774 went some way toward protecting the mentally fit from being wrongly confined, but they would have to wait until the 1840s for legislation that attempted to supervise the living conditions and quality of care of the patients.

During the first part of the nineteenth century, there grew to be a body of treatments which we can increasingly recognize as psychiatric. “In particular, currents in metaphysics and medicine were proposing fresh paradigms of mind and body, behavior and self, and thereby opening a new field eventually to be denominated the psychiatric. For this, the catalyst proved to be the associated emergence of bricks-and-mortar institutions for lunatics; for the presence of the first time of concentrations of patients isolated in madhouses, encouraged close ‘scientific’ surveillance of delusions and delinquencies, stirring the clinical ‘psychology’ of the disturbed. This hitherto unparalleled scrutiny of lunatics under controlled conditions, particularly while interacting with keepers, formed the matrix for practical (experimental) discipline of managing madness” (p. 178).

Much of the book, especially the second half, was bogged down in doctors and case studies of individual patients, which really subtracted from the bigger picture that Porter is trying to illustrate here. This usually isn’t a problem for me, but it was the equivalent of zooming too close in a photograph and losing focus. Had it not been for these minutiae, it story could have been much more effective. However, because of my interest in the topic, I still want to read Porter’s “The Greatest Benefit to Mankind: The Medical History of Humanity.”

'London was always a muddle that worked. Will it remain that way?' is Roy Porter's closing question in this extensive, but engrossing, work. I chose his final remark to start this review because it encapsulates his view that London is "not the eternal city" and, he argues, may well now be at its end as a livable metropolis. Pessimistically he argues that it was at its greatest " ... between the two Elizabeths, between 1570 and 1986 to be more precise..." and he seems to sincerely fret that, once again, as in Roman times, London might be abandoned and "left to the dogs".

Certainly he presents the evidence that London grew too fast and too big "like a fungus" and he details the social and human dimension of that massive growth - unstructured, uncontrolled and ungoverned. From the mobs, the riots the plagues and the Great Fire came an unruly tradition that was translated into a totally unplanned sprawl as the people moved up, and away, from the collapsing city's origins.

Given the published date it is appropriate that he concentrates on the hardness of the Margaret Thatcher policy years and the dreadful impact that such laissez faire, "market forces" led attitudes to the city's growingly desperate needs for public housing, transport and infrastructure. The industries that provided the employment - that provided the taxes and disposable income for the city's fitness and survival - fled to the provinces (or over-seas). The redevelopment, Porter explains, did nothing to resolve these problems as the jobs that were created were filled by transfer, the housing that was built was so `upscale' that the indigenous could not afford to live in it and the `gentrification' of the East End and London Docks only provided for the Thatcherites of the "greed is good" generation. Tourism is now how London survives as even its traditional money-based `service industries' evacuate the remaining centers, to internet-commute, diversify, down-size or are sold off to foreign interests.

Porter's pessimism then is perhaps justified? We must hope not ... as Dr. Johnson once remarked; London is life and its crumbling and dissolution would be our collective loss.

How professionals are institutionalised by their language.