Madness: a brief history
By Roy Porter Oxford University Press, Oxford, England, and New York, USA, 2002. ISBN 0 19 280266 6, price: £11.99 and US$ 22
Roy Porter's final contribution to the history of medicine, published shortly before his death at 55, is more of an executive summary than a history, even a brief one. But it is a good read, full of provocative insights. Somewhat immodestly described by the author as 'brief, bold, and unbiased', the book seeks to assess the credibility of mainstream views of the history of psychiatry as a steady march towards progress and enlightenment. Though he draws back from saying so outright, it is clear that Porter sees only modest evidence of either progress or enlightenment.
In spite of the title, this is not really a history of madness but a history of psychiatry or rather of the faltering, inconsistent, faddish and often hubristic attempts to determine who is mad, why, and what can be done about it. For each epoch, Porter draws from the ambient culture, expressed in poetry, philosophy or literature, some of the notions, ideologies or outright prejudices that moulded the theory of madness and the clinical responses to it.
For Porter the history of the asylum is emblematic of the instability of both the theory and practice of psychiatry. From the time of Bedlam in London (originally called St Mary of Bethlehem, then Bethlem Royal Hospital, used specifically for the mentally ill from 1402 onwards), the madhouse was the product of a genuine desire to create a safe and relatively salubrious environment for people otherwise exposed to mistreatment by themselves and others. Initially, Pinel, Battie, Chiargui, and other pioneers saw asylums as places of moral reform rooted in respect and concern for the patient. Yet, economic and social pressures, and the inability of psychiatry to get any positive results, soon transformed asylums into warehouses or mere "dust bins for hopeless cases", while, not coincidentally, providing psychiatry with subjects for therapeutic experimentation. Bloodletting and purging gave way to psychosurgery, shock therapies, and, by the mid-20th century, psychopharmacology, transforming no-hope asylums into hospitals and giving psychiatry a much-needed "lifeline back into mainstream general medicine".
Is this progress? The discipline of psychiatry may have weathered the storm of Szasz, Laing and the anti-psychiatry movement, and in wealthier countries psychopharmacology may be reducing the need for institutionalization. But, as Porter remarks, pacifying patients with drugs hardly seems like the pinnacle of clinical achievement and, even today, claims about the maturity of a science of mental disorders seem somewhat premature and contestable.
Current trends do not bode well for the future either. In the last couple of decades, psychiatry seems to be shifting its attention to "milder" or "borderline" cases of mental abnormality (arguably within the range of normal variability), with a concomitant expansion in complexes and syndromes. "These days," Porter writes, "clinics and techniques for psycho-social problems, sexual dysfunctions, eating disorders, and personal relations continue to proliferate while prospects are held out of a pill for every psychological ill."
The psychopharmacology industry is undoubtedly the driving force in this expansion in the number of mental disorders and lowering of the threshold of complaint. One sometimes suspects that the chemical treatment antedates the disease and helps to give it an official existence. Should we not be concerned about the tendency to use pharmaceutical products to reshape personalities on the one hand, while creating new and ever more nuanced varieties of madness on the other "especially when the development, manufacture, and marketing of such drugs lie in the hands of monopolistic multinationals"? One can only speculate where, but for his much too early death, these questions might have taken Porter in his future writings. 
Jerome E. Bickenbach
Professor, Philosophy Department, Queen's University, Kingston, Ontario, Canada (email: bickenba@post.queensu.ca).