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."